unitedhealthcare community plan · services at 1-800-701-7192 (tty: 711). a unitedhealthcare...

CA P I TA L A R E A

UnitedHealthcare Community PlanAlliance Member Handbook

941-1057 8/11

Alliance Member Handbook

Your Health Providers

Name: ____________________________________ Phone: ___________________________________

Name: ____________________________________ Phone: ___________________________________

Name: ____________________________________ Phone: ___________________________________

Emergency Room: __________________________ Phone: ___________________________________

Pharmacy: _________________________________ Phone: ___________________________________

Important Phone Numbers

Member Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-701-7192 (8 a .m .–5:30 p .m ., Monday–Friday) . . . . . . . . . . . . . . . . . TTY: 711

NurseLine Services (24 hours a day, 7 days a week) . . . . . . . . . . . . . . . . . . . . . 1-877-237-0006 TTY/TDD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-855-2880

Department of Mental Health Hotline (24 hours a day, 7 days a week) . . . . . . . . . . . . . . . . . . . . . 1-888-793-4357

For aN eMergeNCy, DiaL 911 or go to yoUr NeareSt iN NetWorK eMergeNCy rooM.

Website www.uhccommunityplan.com

1225 I Street, NW, #510Washington, DC 20005 Local Phone: 202-218-7860 TTY: 711(8 a .m . - 5:30 p .m . Monday - Friday)

Alliance Member Handbook

table of Contents

Welcome to UnitedHealthcare Community Plan . . . . . . .2

How this handbook works . . . . . . . . . . . . . . . . 2How this member handbook can help you . . . 3

your Member iD Card . . . . . . . . . . . . . . . . . . . 3

your Primary Care Provider (PCP) . . . . . . . .4How to change your PCP . . . . . . . . . . . . . . . . 4

Making an appointment. . . . . . . . . . . . . . . . .4Changing or canceling an appointment . . . . . 5Getting care when

your PCP’s office is closed . . . . . . . . . . . . . 5How long it takes to see your doctor . . . . . . . 5

routine Care, Urgent Care and emergency Care . . . . . . . . . . . . . . . . . . . .6

Routine care . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Urgent care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Emergency care . . . . . . . . . . . . . . . . . . . . . . . . 6

When you are out-of-town . . . . . . . . . . . . . .7

Support Services . . . . . . . . . . . . . . . . . . . . . . .8Interpretation and translation services/

services for the deaf/hard-of-hearing and visually impaired . . . . . . . . . . . . . . . . . . . 8

Specialty Care . . . . . . . . . . . . . . . . . . . . . . . . .8How to get specialty care . . . . . . . . . . . . . . . . 8Self-referral services . . . . . . . . . . . . . . . . . . . . . 9Birth control and other family

planning services . . . . . . . . . . . . . . . . . . . . . . 9Pharmacy services and prescription drugs . 10Disease management . . . . . . . . . . . . . . . . . . . 10

Services to Keep adults Healthy . . . . . . . .11Recommendations

for checkups (“screenings”) . . . . . . . . . . . . 11Preventive counseling . . . . . . . . . . . . . . . . . . . 11Adult immunizations . . . . . . . . . . . . . . . . . . . . 11

Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Prenatal and postpartum care . . . . . . . . . . . . 12Having a baby . . . . . . . . . . . . . . . . . . . . . . . . . 12Healthy First Steps™ pregnancy program . . 12

your Health Benefits . . . . . . . . . . . . . . . . . .13Covered services . . . . . . . . . . . . . . . . . . . . . . 13Services we do not pay for . . . . . . . . . . . . . . 16

UnitedHealthcare Providers and Providers Who are Not Part of UnitedHealthcare . . . . . . . . . . . . . . . . . . . . .16

other important information . . . . . . . . . . . .17What to do if you move . . . . . . . . . . . . . . . . . 17What to do if you have a baby . . . . . . . . . . . . 17What to do if you adopt a child . . . . . . . . . . . 17What to do if someone in your family dies . . 17How to change your MCO . . . . . . . . . . . . . . . 17What to do if you get a bill

for a covered service . . . . . . . . . . . . . . . . . . 18Paying for non-covered services . . . . . . . . . . 18Advance directives . . . . . . . . . . . . . . . . . . . . . 18What to do if you have other insurance . . . . 18

Complaints/grievances, appeals and Fair Hearings . . . . . . . . . . . . .19

Complaints/grievances . . . . . . . . . . . . . . . . . 19Appeals and fair hearing . . . . . . . . . . . . . . . . 19Deadlines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Expedited (emergency) appeals process . . . 20Your rights during the process . . . . . . . . . . . 20

your rights and responsibilities . . . . . . . 21

Protected Health information . . . . . . . . . . .23Notice of Privacy Practice . . . . . . . . . . . . . . . 23Medical Information-Privacy Notice . . . . . . . . 23Financial Information-Privacy Notice . . . . . . . 28Unitedhealth Group Health Plan

Notice of Privacy Practices: Federal and State Amendments . . . . . . . . . 29

What Some Words Mean . . . . . . . . . . . . . . .33

1Capital Area

We are happy to have you as a member. If you haven’t received your UnitedHealthcare Community Plan member identification card in the mail, it will arrive shortly. Remember to take this card to all of your doctor appointments and show your card to your doctor’s office staff. If you do not receive your identification card, please call Member Services at 1-800-701-7192 (TTY: 711).

A UnitedHealthcare representative will contact you within sixty days of your enrollment to help you understand your benefits and services. These sessions will include, but will not be limited to, the following benefits and services:

• Howtoaccessservices• MemberServicesfunctions• Reviewofmemberhandbook• Pharmacyandprescriptionservices• Complaintandgrievanceprocess• Denials/appealsprocess• Afterhourscare• Out-of-areacare• Careanddiseasemanagementservice• Dentalandvisionservices• Memberrightsandresponsibilities• Healtheducationprogramandservices• RoleofthePCP• AppropriateuseoftheInNetwork

emergency room

All enrollees identified during new member orientation who do not speak or read English will receive member materials in their preferred language.

Here are some of the great benefits of being a UnitedHealthcare member:

• Nocopayments• TheHealthyFirstStepsprogramthat

helps pregnant members have a healthy pregnancy and a healthy baby.

• AdedicatedandfriendlyMemberServices team

• ASpecialNeedsUnit(SNU)tohelpyoufind community-based services in your area

• Personalizedhealthprograms

How this handbook worksUnitedHealthcare Community Plan is a managedcareplanthatispaidbytheDistrictof Columbia to help you get health care. In this handbook we tell you about how UnitedHealthcare works, how to find doctors, how to call us, and what things we pay for.

Telling you about these things can be hard to do – and hard for everyone to read. Words used in health care and words used by your doctor can sometimes be hard to understand. Sometimes we have to tell you about laws that you need to know about. These also can be hard to understand. Some words that might have a different meaning from the one you know. To help you, we have explained these words in the back of this book.

If you ever have any questions about things you read in this book or other questions about UnitedHealthcare, you can call Member Services at 1-800-701-7192 or visit www.uhccommunityplan.com and we will do our best to help you.

Welcome to UnitedHealthcare Community Plan!

2 Alliance Member Handbook

How this member handbook can help youThis member handbook tells you:

• Howtogethealthcare• Whatserviceswewillpayfor(wecall

this, what services are “covered” by us)• Whatserviceswecan’tpayfor• Howtopickyourprimarycareprovider

• Whattodoifyougetsick• Whatyoushoulddoifyouhavea

complaint (also called a “grievance”) or want to change (“appeal”) a decision by UnitedHealthcare

This member handbook gives you basic information about how UnitedHealthcare Community Plan works and its rules. Please call Member Services if you have any questions.

After you sign up for UnitedHealthcare Community Plan and you have picked a primary care provider (PCP), we will send youamemberIDcardinthemail.Thiscard lets your doctors, hospitals, drug stores and others know that you are a member of UnitedHealthcare. Please make sure that the information on your member identification card is correct. If there are any problems, or if you have lost your card, call UnitedHealthcare Member Services at 1-800-701-7192.

OnthebackofyourcardyoucanfindaMember Services telephone number, a number for providers to call and UnitedHealthcare’s website address at www.uhccommunityplan.com.

Each UnitedHealthcare member has his or her own card. Your children will also have their own cards. You must keep your children’s cards so they don’t get lost. It is against the lawtoletanyoneelseuseyourmemberIDcard or Medicaid card.

Please remember to carry your member iD card with you at all times. always show your card before receiving any medical care or getting medicine at a pharmacy.

your Member iD Card

Your member ID card looks like this:

Member ID number

Member name

Member’s Alliance number

Member’s PCP

PCP’s phone number

PCP’s address

Number for provider’s use when submitting claims

Pharmacy information

Member’s health plan

3Capital Area

your Primary Care Provider (PCP)

When you join UnitedHealthcare Community Plan, one of our doctors will be assigned to you as your main doctor. This person is called your primary care provider or PCP. Your PCP will help youandyourfamilygetthehealthcareyouneed.IfyouneedaProviderDirectorypleasecontactMember Services at 1-800-701-7192.

It is important to call your PCP first when you need care. If you had a doctor before you signed up with UnitedHealthcare, please call Member Services at 1-800-701-7192. We can help you stay with that doctor if you would like.

How to change your PCPYoucanchangeyourPCPanytime.JustpickanewPCPfromtheProviderDirectory.CallMemberServices at 1-800-701-7192 once you have picked a new PCP. If you need help picking a new PCP, Member Services can help you.

Making an appointment With your PCP

1.HaveyourmemberIDcardandapenciland paper close by.

2 Call your PCP’s office. Look for your PCP’s phone number on the front of your memberIDcard.Youcanalsofinditinyour provider directory or online at www.uhccommunityplan.com.

3. Tell the person who answers that you are a UnitedHealthcare Alliance member. Tell them you want to make an appointment with your PCP.

4. Tell the person why you need an appointment.Forexample:

- You or a family member is feeling sick - You hurt yourself or had an accident - You need a check up or follow-up care

5. Write down the time and date of your appointment.

6. Come to your appointment on time and bringyourmemberIDcardwithyou.

7. If you need help making an appointment, please call Member Services at 1-800-701-7192.

if you are a new member of UnitedHealthcare Community Plan, you should make an appointment for your first health check-up as soon as possible.


Changing or canceling an appointmentIt is very important to come to your appointments and to be on time.

• Ifyouneedtochangeorcancelyour appointment, please call the doctor at least 24 hours before your appointment.

• Forsomeappointments,youmayhave to call more than 24 hours before to cancel.

• Ifyoudonotshowupforyourappointment or if you are late, your doctor may decide you cannot be his or her patient.

How long it takes to see your doctorYour doctor’s office must give you an appointment within a certain number of days after you call. The table below shows how long it will take to get an appointment. Please call 1-800-701-7192 if you cannot get an appointment during these time periods.

Type of visit Your condition Appointment time frame

Urgent visitYou are hurt or sick and need care within 24 hours to avoid getting worse. Examples of urgent care conditions are sprains, sore throats or rising temperatures.

Within 24 hours

Routine visit You have a minor illness or injury or you need a regular checkup, but you don’t need an urgent appointment. Within 30 days

Follow-up visit You need to see your doctor after a treatment you just had to make sure you are healing well.

Within 1-2 weeks depending on the kind of treatment

Adult wellness visits

You are having your first appointment with a new doctor

You are due for a regular adult checkup

You are due for a prostate exam, a pelvic exam, a PAP smear or a breast exam

Within 30 days or sooner if necessary

Non-urgent appointments with specialists (by referral)

Your PCP referred you to see a specialist for a non-urgent condition Within 30 days

Getting care when your PCP’s office is closedIf you need to speak to your PCP when the office is closed, call your PCP’s office and leave a message with the person who answers the phone when the office is closed. Be sure to give the person who answers your phone number. Someone will call you back as soon as possible.Youcanalsocallour24/7NurseLineservicesat 1-877-237-0006. If you think you are having an emergency, call 911 or go to the emergency room. If you think you are having an emergency, call 911 or go to the emergency room of a network provider. Alliance members do not have coverage for any service that you get from an out of network provider, including emergency services. You will be responsible for the charges for the out of network services.

5Capital Area

routine Care, Urgent Care and emergency Care

Here are three kinds of health care you may need: routine care, urgent care, or emergency care.

routine care is the regular care you get from your PCP. Routine care is also care you get from other doctors that your PCP sends you to. Routine care can be check-ups, physicals, health screenings and care for health problems like diabetes, hypertension and asthma. If you need Routine care, call your PCP’s office and ask to make an appointment.

Urgent care is medical care you need within 24 hours, but not right away. Urgent care issues are those when you or a family member needs care, treatment or advice within 24 hours (examples of urgent care conditions are sprains, sore throats or rising temperatures). Urgent care services are medically necessary services which are required for an illness or injury that would not result in further disability or death if not treated immediately, but require professional attention and have the potential to develop such a threat if treatment is delayed longer than 24 hours.

If you need urgent care, call your PCP’s office. If your PCP’s office is closed, leave a message with the person who answers the phone. Then callour24/7NurseLineservicesat1-877-237-0006. A nurse will help you decide if you need to go to the doctor right away. The nurse can tell you how to get care. You should not have to go to the emergency room or use an ambulance for routine or urgent care.

emergency care is medical care you need right away for a serious, sudden (sometimes life-threatening) injury or illness. An emergency

condition is a medical condition that shows itself by sudden or serious symptoms (including severe pain). The symptoms should be such that the average person (prudent layperson), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

If you are not sure if you are having an emergency, or if you would like additional information about medical conditions, please call our24/7NurseLineservicesat1-877-237-0006.

Emergency medical services are needed to assessorstabilizeanemergencymedicalcondition that is found to exist using the prudent layperson standard and during emergency ambulance transportation. Some examples of emergencies are:

• Heartattacks• Severechestpains• Accidents• Severebleeding• Majorburns• Lossofconsciousness• Seriousbreathingdifficulties• Spinalinjuries

Colds and sore throats are not usually emergencies. If you are not sure if you are having an emergency, call your PCP. If the office is closed, a message will give you further instructions. Go to the nearest In Network emergency room when you have an emergency.


If you receive emergency treatment, you should call UnitedHealthcare Community Plan within 24 hours, or as soon as possible (1-800-701-7192). This number is listed on yourUnitedHealthcareCommunityPlanIDcard. You will need to call your PCP as soon as possible after the emergency is under control.

WHat to Do iF yoU HaVe aN eMergeNCy:

1 . Call 9-1-1 or go to your nearest In Network emergency room .

2 . Show the emergency room (ER) your UnitedHealthcare Community Plan member ID card .

3 . Alliance members do not have coverage for any service outside of the network including emergency services .

4 . As soon as you can, call your PCP .

When you are out-of-town

When you need to see a doctor or get medicine when you are out-of-town, you should:

For routine care: You must call us and ask if we will pay for you to see a doctor or other provider when you are out of town. If UnitedHealthcare Community Plan does not say it will pay for the care, you will have to pay for the care yourself. If you need medicine from a doctor while you are out-of-town, generally UnitedHealthcare only covers medications in limited, non-routine circumstances such as emergencies. You can go to any participating pharmacy in the UnitedHealthcare network. Call Member Services if you need help finding a pharmacy. This number is also on the back ofyourUnitedHealthcareIDcard.Wewillassist the pharmacist in processing any urgently-needed medications.

For urgent care: Call your PCP. If your PCP’sofficeisclosed,callour24/7NurseLineservices at 1-877-237-0006. A nurse will help you decide if you need to go to the doctor right away. The nurse can tell you how to get care. You do not have to go to the emergency room or use an ambulance for routine or urgent care.

For emergency care: If you have an emergency, including a mental health or alcohol or other drug emergency, go to the nearest In Network emergency room (ER) to get care right away. If you go to the In Network emergency room, you should ask the ER staff to call your PCP. If you go to the emergency room, you should call Member Services as soon as you can. Alliance members do not have coverage for any service outside of the network including emergency services.

7Capital Area

Support Services

Interpretation and translation services/services for the deaf/hard-of-hearing and visually impairedinterpretation servicesUnitedHealthcare Community Plan will provide oral interpretation services if you need them, including at the hospital. Please call Member Services at 1-800-701-7192 to get interpretation services. Please call us before your doctor’s appointment if you will need interpretation services.

Interpreter services are usually provided over the telephone. If you need an interpreter to be with you at your doctor’s appointment, you must let us know 5 days before the appointment.

translation ServicesIf you get information from UnitedHealthcare Community Plan and need it translated into another language, please call Member Services at 1-800-701-7192.

Services for the deaf/hard-of-hearing and visually impaired If you are deaf or hard of hearing, call Member Services via our national relay service by calling 711.

If you have trouble seeing, call Member Services at 1-800-701-7192. We can give you information on an audio tape, in Braille or in large print.

interpretation and translation services and services for the deaf/hard-of-hearing and visually impaired are Free.

How to get specialty careIf you need specialty services, your PCP will help you find a specialist. If you need further assistance, please call Member Services and they will assist you.

If you want to see a specialist, but UnitedHealthcare Community Plan says it will not pay for the specialist, you can:

• Makeanappointmentwithanotherdoctor in UnitedHealthcare’s network and get a second opinion.

• Gotothespecialistandpayforthevisityourself.• Appealourdecision(seepage19onappeals).• Askforafairhearing(seepage19)

Specialty Care


Self-referral servicesThere are certain services you can get without getting prior permission from your PCP. These are called self-referral services. You may self-refer to UnitedHealthcare Community Plan’s participating providers; however, your PCP will work with you to direct your health care. UnitedHealthcare encourages you to work with your PCP to help coordinate access to specialty care. Some examples of self-referral services are listed below. Please call Member Services if you need more information.

you Do Not need a referral to:• SeeyourPCP.• ReceiveservicesfromyourOB/GYN

doctor in your network for routine or preventive services (females only).

• Receivefamilyplanningservices.• Receiveservicesforsexuallytransmitted

diseases(STDs).• Receiveimmunizations(shots).• Visitavisionproviderinthenetwork

(vision services are covered only if you are under 21 years old).

• Receiveemergencymentalhealthservicesin an emergency room for conditions that are life-threatening and related to withdrawal of alcohol or narcotics.

Birth control and other family planning servicesYou can get birth control and other family planning services from any provider you pick. You do not need a referral to get these services. If you choose a family planning services doctor other than your PCP, tell your PCP. It will help your PCP take better care of you.

Talk to your PCP or call UnitedHealthcare Community Plan Member Services at 1-800-701-7192 for more information on birth control or other family planning services.

All birth control and family planning services are confidential.

Family planning services include:• Pregnancytesting• Counselingforthewoman

and the couple• Routineandemergencycontraception• Counselingandimmunizations• Screeningforallsexually

transmitted diseases• Treatmentforallsexually

transmitted diseases• Sterilizationprocedures(requiresyouto

sign a form 30 days before the procedure)• HIV/AIDStestingandcounseling

Family planning services do not include:• Routineinfertilitystudiesorprocedures• Hysterectomyforsterilization• Reversalofvoluntarysterilization• Abortions• HIV/AIDStreatment

9Capital Area

Specialty Care continued

HiV/aiDS testing, counseling and treatment:

• YoucangetHIV/AIDStesting and counseling:

• whenyouhavefamilyplanningservices,• fromyourPCP,and• fromanHIVtestingandcounselingcenter.

ForinformationonwhereyoucangoforHIVtestingandcounseling,callMemberServicesat1-800-701-7192.IfyouneedHIVtreatment, your PCP will help you get care. You can also call UnitedHealthcare’s Special Needs Unit (SNU) at 1-877-844-8844 and ask to speak with a care manager.

Pharmacy services and prescription drugsPharmacies are where you pick up your medicine (drugs). If your doctor gives you a prescription, you must go to a pharmacy in the Alliance pharmacy network for Alliance members.

You can find a list of all the pharmacies in the Alliance pharmacy network in the Alliance formulary or online at www.uhccommunity plan.com.

to get a prescription filled:• Pickapharmacythatispartofthe

Alliance pharmacy network and is close to your work or home.

• Whenyouhaveaprescription,gotothepharmacy and give the pharmacist your prescription and your Alliance member IDcard.

• Ifyouneedhelp,pleasecallMemberServices at 1-800-701-7192.

• Sometimes,yourdoctormayneedtoget permission from UnitedHealthcare Community Plan for a drug that is not on the Alliance formulary.

• IntheeventtheAlliancepharmacyis closed, and you need to fill your prescription,contactyourMCOforpermission to obtain your medication at an alternate pharmacy.

You can get the medication: - Forupto72hoursor - Foronefullroundofthemedicine

if you take it less than once a day.

If you are out of town and you have an emergency or need urgent care, you will need to contact UnitedHealthcare at 1-800-701-7192 and we will help you find a pharmacy where you can get urgently-needed medications.

things to remember:• Youshouldnotbeaskedtopayfor

your medicines. Call UnitedHealthcare Community Plan Member Services if the pharmacy or drug store asks you to pay.

Disease managementIf you have a chronic illness or special health care need such as asthma, diabetes or congestive heart failure, we may include you in our disease management program. Dependingonyourcondition,youmayhaveacare manager. A care manager is someone who works for UnitedHealthcare Community Plan and who will help you get the services and information you need to control your illness and be healthier.


Services to Keep adults Healthy

UnitedHealthcare Community Plan wants you to take care of your health. We also want you to sign up for health and wellness services we offer to you. Health and wellness services include screenings, counseling andimmunizations.

Recommendations for checkups (“screenings”)Please make an appointment and go see your PCP at least one time every year for a checkup. The list below tells you the type of things to talk with your PCP about during your checkup.

adult screening recommendations:• Bloodpressureandcholesterol(lipid

disorder) screening• Sexuallytransmitteddiseases• HIV/AIDSscreeningandtesting• Diabetesscreening• Tobaccouse• Alcoholanddruguse• Depression• Colorectalcancer(50yearsandolder)• Obesity• HepatitisC

Screenings for women only• Breastcancerscreening(mammogram)• Cervicalcancer• Osteoporosis(post-menopausalwomen)• HPVscreening• Chlamydia

Screenings for men only• Prostatecancerscreening• Abdominalaorticaneurysm

Preventive counselingPreventive counseling is available to help you stay healthy. You can get preventive counseling on:

• Dietandexercise• Alcoholanddruguse• Smokingcessation• HIV/AIDSprevention

You will also receive certain health education materials including:

• Membernewslettersthataremailedoutquarterly. The newsletters have articles and information on preventive health and wellness counseling.

• YearlyFlu&Pneumoniareminders• InformationontheDCTobaccoFree

FamiliesQuitline,1-800-QUITNOW(1-800-784-8669).

UnitedHealthcare’s Care Management and Special Needs programs offer support and counseling to help members achieve the best quality of life.

Adult immunizationsIf you are an adult, you may need some immunizations(shots).PleasetalktoyourPCP about which ones you may need.

Please make an appointment to see your PCP at least once a year for a checkup.

11Capital Area

Pregnancy

If you are pregnant or think you are pregnant, it isveryimportantthatyougotoyourOB/GYNdoctor right away. You do not need to see your PCP before making this appointment.

If you are pregnant, you need to call:• IncomeMaintenanceAdministration

(IMA) at 202-727-5355 • MemberServicesat1-800-701-7192• YourPCP

There are certain things that you need to get checked if you are pregnant. These will help make sure that you have a healthy pregnancy, delivery and baby. This is called prenatal care. You get prenatal care before your baby is born.

remember, if you are pregnant or think you are pregnant do not drink alcohol, use drugs or smoke.

Prenatal and postpartum careHaving a babyUnitedHealthcare Community Plan wants you to have a healthy baby. Call Member Services if you are pregnant. The health care a woman receives before the birth of her baby is known as prenatal care. Prenatal care is important. It helps the doctor see how the pregnancy is going. It helps to see if there are any problems. Even if a woman has been pregnant before, going to the doctor often while she is expecting is important. If you have a medical condition like diabetes or you are having twins, your pregnancy may be high risk. If your pregnancy is high risk, your doctor can help you join our high-risk pregnancy program.

Healthy First Steps™ a program for our pregnant members

Healthy moms are more likely to have a healthy baby. Pregnancy is an important time for women. It is a time to take good care of themselves and their unborn baby. Some women may have risk factors that can cause problems during pregnancy. These problems could cause early labor. A baby born too early may be sick or have to stay in the hospital. We want the best possible health for the mom and baby.

We have a special program for pregnant members.OurHealthyFirstSteps™ program gives pregnant women the information, education and support they need during pregnancy.

If you are pregnant, call to enroll in Healthy FirstSteps™at1-800-599-5985.Wewanttohelpyouhaveahealthypregnancy.Ourstaffwill help you get the care you need. We can also help you get ready for the birth and care of your baby.

See a doctor as soon as you think you are pregnant. If you have problems finding a doctor or getting an appointment, we can help you. We can also work with you to locate community services such as WIC, behavioral health care and social services.

LetHealthyFirstSteps™helpyoumakeyourpregnancy the healthiest it can be.

For more information about your children’s health care or health care coverage, please contact Member Services at 1-800-701-7192.

once you have had your baby, call Member Services and your iMa caseworker at 202-724-5506.


your Health Benefits

Health services covered by UnitedHealthcare Community PlanThe list below shows the health care services and benefits for all UnitedHealthcare Community Planmembers.Forsomebenefits,youhavetobeacertainageorhaveacertainneedfortheservice.UnitedHealthcare will not charge you for any of the health care services in this list if you go to a network provider or hospital.

If you have a question about whether UnitedHealthcare covers certain health care, call UnitedHealthcare Member Services at 1-800-701-7192.

Benefit What you get Who can get thisPrimary Care Services • Preventive,acute,andchronichealthcare

services generally provided by your PCP.All members

Specialist Services • Healthcareservicesprovidedbyspecially trained doctors or advanced practice nurses.

• Doesnotincludecosmeticservicesand surgeries except for surgery required to correct a condition resulting from surgery or disease, created by an accidental injury or a congenital deformity, or is a condition that impairs the normal function of your body.

All members

Laboratory and X-ray Services

• LabtestsandX-rays. All members

HospitalServices • Outpatientservices(preventive,diagnostic, therapeutic, rehabilitative, or palliative services).

• Inpatientservices(hospitalstay)withthe exception listed on the following page under “Services we do not pay for.”

• Inpatientpsychiatricservices.

Any member with a referral from their PCP or who has an

emergency

Pharmacy Services (prescription drugs)

• PrescriptiondrugsincludedontheAlliance drug formulary are available only from Alliance program pharmacies. You can find the drug formulary at www.uhccommunityplan.com or by calling Member Services. The Alliance formulary may be obtained by having your doctor contact theUnitedHealthcarePharmacyDepartment.

All members

13Capital Area

Benefit What you get Who can get thisIn Network Emergency Services

• Ascreeningexamofyourhealthcondition and stabilization if you have an emergency medical condition, if the provider is in the network.

• Treatmentforemergencyconditions.

All members

Family Planning • Pregnancytesting; counseling for the woman.

• Routineandemergencycontraception.

• Voluntarysterilizationsformembersover 21 years of age (requires signature of an approved sterilization form by the member 30 days prior to the procedure).

• Screening,counselingandimmunizations(includingforHPV).

• Screeningandpreventivetreatmentforall sexually transmitted diseases.

• Doesnotincludesterilizationprocedures for members under age 21.

All members as appropriate

Podiatry • Specialcareforfootproblems.

• Regularfootcarewhenmedicallyneeded.

All members

Rehabilitation Services • Rehabilitationservices,includingphysical,speech and occupational therapy.

All members

Prosthetic Devices • Replacement,corrective,orsupportivedevices prescribed by a licensed provider.

All members

VisionCare • Eyeexamsatleastonceeveryyearandasneeded;andeyeglasses(correctivelenses) as needed.

Members under 21

HomeHealthServices In-home health care services, including:

• Nursingandhomehealthaidecare.

• Homehealthaideservicesprovidedbya home health agency.

• Physicaltherapy,occupationaltherapy,speech pathology and audiology services.

All members

Sub-Acute Care • Sub-acutecarefor30consecutivedays. All membersMentalHealthServices • Inpatientmentalhealthservices. All membersNursingHomeCare • Full-timeskillednursingcareina

nursing home.All members

HospiceCare • Supportservicesforpeoplewhoaredying. All membersTransportation Services • Transportationforemergencyservices. All members


Benefit What you get Who can get thisAdult Wellness Services • Immunizations.

• Routinescreeningforsexuallytransmitted diseases.

• HIV/AIDSscreening,testingandcounseling.

• Breastcancerscreening(womenonly).

• Cervicalcancerscreening (women only).

• Osteoporosisscreening (post-menopausal women).

• HPVscreening(womenonly).

•Prostatecancerscreening(menonly).

• Abdominalaorticaneurysmscreening(men only).

• Screeningforobesity.

• Diabetesscreening.

• Screeningforhighbloodpressureandcholesterol (lipid disorders).

• Screeningfordepression.

• Colorectalcancerscreening(members50 years and older).

• Smokingcessationcounseling.

• Dietandexercisecounseling.

• Mentalhealthcounseling.

• Alcoholanddrugscreening.

Members over 21 as appropriate

DentalBenefits • Generaldentistry(includingregularandemergency treatment) and orthodontic care for special problems.

• Check-upstwiceayearwithadentist.

• Doesnotincluderoutineorthodonticcare.

• IncludesX-rays,extractionsandfillings.

All members

Orthodonticcareonlyfor members under 21

HearingBenefits • Diagnosisandtreatmentofconditionsrelated to hearing, including hearing aids and hearing aid batteries.

Members under 21

Durable Medical Equipment (DME) and Disposable Medical Supplies (DMS)

• DurableMedicalEquipment(DME).

• DisposableMedicalSupplies(DMS).

All members

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Services we do not pay for• Acupuncture.• Alcoholandotherdrugabuseservices.• Chiropracticservices.• Cosmeticsurgery.• Deliveries(ifyouarepregnant,contact

the Income Maintenance Administration at 202-727-5355 to determine eligibility forMedicaid.DeliveriesarecoveredbyMedicaid. Contact your IMA caseworker if you become pregnant to ensure Medicaid coverage).

• Experimentaltreatmentandinvestigational services and items.

• Hearingservicesformembersover21.• Infertilitytestingandservices.• Outpatientmentalhealthservices.

• Non-emergencytransportationservices.• Openheartsurgery.• Organtransplantation.• Privatedutynursing.• Sclerotherapyservicesanditems.• Servicesfurnishedinschools.• Screeningandstabilizationservicesfor

emergency medical condition outside of the network including inside of the District.Youwillberesponsibleforthecharges for the out of network services including emergency services

• Treatmentforobesity.• VisionServicesformembersover21.• Anycoveredserviceswhenfurnishedby

providers that are not members of the network.

UnitedHealthcare Community Plan will pay for the care you get when you go to one of our doctors or other health care providers. We call these doctors and other health care providers our “network” providers. All these “in-network” doctors can be found in your provider directory. A doctor or provider who is not one of ours is called an “out-of-network” provider.

If you go to an “out-of-network” doctor, hospital or lab, you may have to pay for the care you get. You will not have to pay if you have asked us first and we have told you, usually in writing, that it is okay. We call this “priorwrittenauthorization.”

remember: you need to go to a provider in UnitedHealthcare Community Plan’s network.

UnitedHealthcare providers and providers who are not part of UnitedHealthcare Community Plan

Prior authorization (or prior approval) means approval for a health service that is not routinely covered by UnitedHealthcare Community Plan. you must get this approval before you receive the service. Call Member Services at 1-800-701-7192 to ask about getting a prior authorization.

your Health Benefits (cont.)


other important information

What to do if you move• CalltheDistrictofColumbia(DC)

Income Maintenance Administration (IMA) Change Center at 202-724-5506

• CallUnitedHealthcareCommunityPlanMember Services at 1-800-701-7192.

What to do if you have a baby• CallDCIncomeMaintenance

Administration (IMA) Change Center at 202-724-5506.


What to do if you adopt a child• CallDCIncomeMaintenance


What to do if someone in your family dies• CallDCIncomeMaintenance



How to change your MCo• YoucanchangeyourMCOonceayear

within the 90 days after your anniversary date – the month and date you first joined UnitedHealthcare Community Plan.

• TheDistrictofColumbiawillsendyoualetter two months before your anniversary date. The letter tells you how to change MCOs.

You will not be allowed to get health care from UnitedHealthcare anymore if you:

• LoseyourAllianceeligibilityforreasonssuch as:

- You reside outside oftheDistrictofColumbia

- You are over-income for the Alliance program

• EstablishSocialSecurityIncome (SSI) eligibility

Changing your MCo if you have a good reasonYouhavetherighttochangeyourMCOatany time after the first 90 days of enrollment if you have a good reason. Examples of good reasons are poor quality of care and you can’t see the providers you need. You may change yourMCOifyourPCPterminatesfromthe UnitedHealthcare network, and you are unwilling or unable to select a new PCP. CalltheDCHealthCareAllianceat 202-639-4030 if you would like more informationonhowtochangeMCOs.

the D.C. government may remove you from UnitedHealthcare Community Plan if you:

• LetsomeoneelseuseyourmemberIDcard,• TheDistrictfindsyoucommittedfraud,or• Youdonotfollowyourmember

responsibilities.

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What to do if you get a bill for a covered serviceIf you get a bill for a covered service that is in the list above, call Member Services at 1-800-701-7192.

Paying for non-covered services

• Ifyoudecideyouwantaservicethat we do not pay for and you do not have written permission from UnitedHealthcare Community Plan, you will have to pay for the service yourself.

• Ifyoudecidetogetaservicethatwedonot pay for, you must sign a statement that you agree to pay for the service yourself.

• RemembertoalwaysshowyourmemberIDcardandtelldoctorsthatyouareamember of UnitedHealthcare before you get services.

Advance directivesAn advance directive is a legal document you sign that lets others know your health care choices. It is used when you are not able to speak for yourself. Sometimes this is called a “living will” or a “durable power of attorney.”

An advance directive can let you pick a person to make choices about your medical care for you. An advance directive also lets you say what kind of medical treatment you want to receive if you become too ill to tell others what your wishes are.

• Itisimportanttotalkaboutan advance directive with your family, your PCP, or others who might help you with these things.

• Ifyouwanttofilloutandsignanadvancedirective, ask your PCP for help during your next appointment, or call Member Services at 1-800-701-7192 and they will help you.

What to do if you have other insuranceIf you are a member of UnitedHealthcare Community Plan and eligible for Alliance, you must tell us right away if you have any other health insurance. Please call Member Services at 1-800-701-7192 and tell us right away.

other important information (cont.)


Complaints/grievances, appeals and Fair Hearings

UnitedHealthcare Community Plan and the D.C.governmentbothhavewaysthatyoucanfile a complaint about the care you get or the services UnitedHealthcare provides to you. You may choose how you would like to complain as described below.

Complaints/grievancesIf you are unhappy with something that happenedtoyou,youcanfileacomplaint/grievance. Examples of why you might file a complaint/grievanceinclude:

• Youfeelyouwerenottreatedwithrespect• UnitedHealthcareCommunityPlanhas

denied payment for a service you believed is covered

• Youarenotsatisfiedwiththehealth care you got

• Ittooktoolongtogetanappointment• Tofileacomplaint/grievance,youshould

call Member Services at 1-800-701-7192.• Yourdoctorcanalsofileacomplaint/

grievance for you.

Youshouldfileacomplaint/grievanceassoonaspossible and no later than 90 days after the thing you are unhappy about. UnitedHealthcare will usually give you a decision within 30 days but may ask for extra time (but not more than 44 days total) to give a decision.

Appeals and fair hearingsIf you believe your benefits were unfairly denied, reduced, delayed or stopped, you have a right to file an appeal with UnitedHealthcare Community Plan and request a “fair hearing” withtheD.C.OfficeofAdministrativeHearings.

• TofileanappealwithUnitedHealthcare,call Member Services at 1-800-701-7192.

• Tofilearequestforafairhearing,callorwritetheDistrictgovernmentat:

D.C.OfficeofAdministrativeHearings 441 4th Street, N.W. Suite 450-North Washington,DC20001

Telephone Number: 202-442-9094

Deadlines•Youmustfileanappealorrequesta

fair hearing within 90 days of getting UnitedHealthcare Community Plan’s notice of action.

•Ifyouwanttocontinuereceivingthebenefitduring your fair hearing or appeal, you must request the fair hearing or appeal within the later of the follow- Within 15 days from UnitedHealthcare’s

postmark of the Notice of Action or- The intended effective date of

UnitedHealthcare’s proposed action (or, in other words, when the benefit is to stop).

- Your provider may file an appeal on your behalf with your written permission. You may also choose to have your provider with you at the hearing.

Appeals• Ifyoucallandgiveyourappealoverthe

phone, UnitedHealthcare Community Plan willsummarizeyourappealinaletterandsend you the letter for you to sign. Be sure to read the letter carefully. You must sign the letter and return it to UnitedHealthcare in order to have an appeal.

• YourappealwillbedecidedbyUnitedHealthcare within 14 calendar days from the date your appeal was received.

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• IfUnitedHealthcareneedsmoretimetogetinformationandtheDistrictdecidesthis would be best for you, or if you or your advocate requests more time, UnitedHealthcare may increase this time period for the decision by 14 calendar days. UnitedHealthcare must give you written notice of the extension.

• YouwillreceivewrittennoticeofUnitedHealthcare’s decision about your appeal in the mail.

• IfyouarenothappywithUnitedHealthcare’s decision about your appeal you may request a fair hearing.

Expedited (Emergency) appeals processIf your appeal is determined to be an emergency, UnitedHealthcare Community Plan will give you a decision within 3 calendar days. An appeal is considered an emergency if it would be harmful or painful to you if you had to wait for the standard time frame of the appeal procedure.

AllappealsfiledbymemberswithHIV/AIDS,mental illness or any other condition that requires attention right away, will be resolved and communicated back to the member within 24 hours of filing the appeal.

Your rights during the complaints/grievances, appeals and fair hearings process

• Youhavetherighttoafairhearing.YoumayrequestafairhearingfromtheOfficeofAdministrative Hearings at any time before,

during or after you have filed an appeal with UnitedHealthcare Community Plan, but no more than ninety (90) days from the date Notice of Action is mailed.

• Youhavearighttokeepreceivingthebenefitwe denied while your appeal or fair hearing is being reviewed. To keep your benefit during an appeal or fair hearing, you must file the appeal or request the fair hearing within a certain number of days - this could be as short as 15 days from the postmark of theMCO’sNoticeofAction.

• YouhavetherighttohavesomeonefromUnitedHealthcare help you through the grievance and appeals process.

• Youhavearighttorepresentyourselforberepresented by your family caregiver, lawyer or other representative.

• Youhavearighttohaveaccommodationsmade for any special health care need you have.

• YouhavearighttoadequateTTY/ TTDcapabilities,andservicesforthevisually impaired.

• Youhavearighttoadequatetranslationservices and an interpreter.

• Youhavearighttoseealldocuments relatedtothecomplaint/grievance,appeal or fair hearing.

Ifyouhaveanyquestionsaboutthecomplaints/grievancesandappeals/fairhearingsprocess,please call Member Services at 1-800-701-7192.

Complaints/grievances, appeals and Fair Hearings (cont.)


You have a right to:• Betreatedwithrespectanddignity.• Knowthatwhenyoutalkwithyour

doctors and other providers its private.• Haveanillnessortreatmentexplainedto

you in a language you can understand.• Participateindecisionsaboutyourcare.• Receiveafull,clearandunderstandable

explanation of treatment options and risks of each option so you can make an informed decision.

• Refusetreatmentorcare.• Befreeofphysicalandchemicalrestraints.• Beabletoseeyourmedicalrecordsandto

request that they be fixed if they are wrong.• ChooseaneligiblePCPfromwithin

UnitedHealthcare Community Plan’s network and to change your PCP.

• Makeacomplaint(“grievance”)aboutthecare provided to you and receive an answer.

• Requestanappealorafairhearingif you believe UnitedHealthcare was wrong in denying, reducing or stopping a service or item.

• Receivefamilyplanningservicesandsupplies from the provider of your choice.

• Obtainmedicalcarewithout unnecessary delay.

• Receiveinformationonadvancedirectivesand choose not to have or continue any life-sustaining treatment.

• ReceiveacopyofthisUnitedHealthcaremember handbook.

• Continuetreatmentyouare currently receiving until you have a new treatment plan.

• Receiveinterpretationandtranslationservices free of charge if you need them.

• Refuseoralinterpretationservices.• Getanexplanationofpriorauthorization

procedures.• Receiveinformationabout

UnitedHealthcare, its services, and its providers and practitioners.

• ReceiveinformationaboutUnitedHealthcare’s financial condition and any special ways we pay our doctors.

• Obtainsummariesofcustomersatisfaction surveys.

• ReceiveUnitedHealthcare’s“DispenseAsWritten” policy for prescription drugs.

• ReceiveUnitedHealthcare’smemberrights and responsibilities policy and make recommendations for it.

• Tobefreefromseclusionasameans of coercion, discipline, convenience or retaliation.

your rights and responsibilities

21Capital Area

You are responsible for:• Treatingthoseprovidingyourcarewith

respect and dignity.• FollowingtherulesoftheD.C.

HealthCare Community Plan Alliance Program and UnitedHealthcare Community Plan.

• Followinginstructionsyoureceivefromyour doctors and other providers.

• Goingtoappointmentsyouscheduleorthat UnitedHealthcare schedules for you.

• Tellingyourdoctoratleast24hoursbeforethe appointment if you have to cancel.

• Askingformoreexplanationifyoudonotunderstand your doctor’s instructions.

• Goingtotheemergencyroomwhenyouhave a medical emergency.

• TellingyourPCPaboutmedical and personal problems that may affect your health.

• ReportingtoIncomeMaintenanceAdministration (IMA) and UnitedHealthcare if you or a family member have other health insurance.

• Tryingtounderstandyourhealthproblems and participate in developing treatment goals.

• Helpingyourdoctoringettingmedicalrecords from providers who have treated you in the past.

• TellingUnitedHealthcareifyou were injured as the result of an accident or at work.

your rights and responsibilities (cont.)


We train our employees to make sure that they handle your protected health information the right way. This includes information that is spoken, written or electronic. Unless authorizedbyyou,wewillnotprovideanyof your protected health information to anyone outside the company or to anyone who is not a business associate under contract with the company for any reason beyond the requirements of your treatment, payment for services, and our health care operations.

Notice of Privacy PracticesMeDiCaL iNForMatioN - PriVaCy NotiCeThis says how medical information about you may be used and shared. It says how you can get access to this information. Read it carefully.

Effective January 1, 2011

We1 are required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or “disclose” that information to others. You also have rights regarding your health information that are described in this notice. We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we

make a material change to our privacy practices, we will provide to you a revised notice by direct mail or electronically as permitted by applicable law. In all cases, we will post the revised notice on your health plan website, www.myuhc.com. We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.

How We Use or Disclose informationWe must use and disclose your health information to provide that information:

• Toyouorsomeonewhohasthelegalright to act for you (your personal representative) in order to administer your rights as described in this notice; and

• TotheSecretaryoftheDepartmentofHealth and Human Services, if necessary, to make sure your privacy is protected.

We have the right to use and disclose health information for your treatment, to pay for your health care and to operate our business. Forexample,wemayuseordiscloseyourhealth information:

•ForPaymentofpremiumsdueus,todetermine your coverage, and to process claims for health care services you receive, including for subrogation or coordination ofotherbenefitsyoumayhave.Forexample, we may tell a doctor whether you are eligible for coverage and what percentage of the bill may be covered.

•ForTreatment.Wemayuseordisclosehealth information to aid in your treatment or the coordination of your care.Forexample,wemaydiscloseinformation to your physicians or hospitals to help them provide medical care to you.

Protected Health information

23Capital Area

•ForHealthCareOperations.Wemayuse or disclose health information as necessary to operate and manage our business activities related to providing and managingyourhealthcarecoverage.Forexample, we might talk to your physician to suggest a disease management or wellness program that could help improve yourhealthorwemayanalyzedata to determine how we can improve our services.

•ToProvideYouInformationonHealthRelated Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law.

•ForPlanSponsors.Ifyourcoverageisthrough an employer sponsored group health plan, we may share summary health information and enrollment and disenrollment information with the plan sponsor. In addition, we may share other health information with the plan sponsor for plan administration if the plan sponsor agrees to special restrictions on its use and disclosure of the information in accordance with federal law.

•ForReminders.Wemayuseordisclosehealth information to send you reminders about your benefits or care, such as appointment reminders with providers who provide medical care to you.

We may use or disclose your health information for the following purposes under limited circumstances:

• AsRequiredbyLaw.Wemaydiscloseinformation when required to do so by law.

• ToPersonsInvolvedWithYourCare.We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity. If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.

• ForPublicHealthActivitiessuchasreporting or preventing disease outbreaks.

• ForReportingVictimsofAbuse,NeglectorDomesticViolencetogovernmentauthoritiesthatareauthorizedbylawto receive such information, including a social service or protective service agency.

• ForHealthOversightActivitiestoahealth oversight agency for activities authorizedbylaw,suchaslicensure,governmental audits and fraud and abuse investigations.

• ForJudicialorAdministrativeProceedings such as in response to a court order, search warrant or subpoena.

• ForLawEnforcementPurposes.Wemaydisclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.

• ToAvoidaSeriousThreattoHealthor Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster.

• ForSpecializedGovernmentFunctionssuch as military and veteran activities, national security and intelligence

Protected Health information (cont.)


activities, and the protective services for the President and others.

• ForWorkers’Compensationasauthorizedby, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.

• ForResearchPurposessuchasresearchrelated to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.

• ToProvideInformationRegardingDecedents.Wemaydiscloseinformationto a coroner or medical examiner to identify a deceased person, determine a causeofdeath,orasauthorizedbylaw.We may also disclose information to funeral directors as necessary to carry out their duties.

• ForOrganProcurementPurposes.Wemay use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.

• ToCorrectionalInstitutionsorLawEnforcementOfficialsifyouareaninmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

• ToBusinessAssociatesthatperformfunctions on our behalf or provide us with services if the information is necessary for suchfunctionsorservices.Ourbusinessassociates are required, under contract with us, to protect the privacy of your

information and are not allowed to use or disclose any information other than as specified in our contract.

• ForDataBreachNotificationPurposes.We may use your contact information to provide legally-required notices of unauthorizedacquisition,access,ordisclosure of your health information. We may send notice directly to you or provide notice to the sponsor of your plan through which you receive coverage.

• AdditionalRestrictionsonUseandDisclosure.Certainfederalandstatelawsmay require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information underFederallawsgoverningalcoholand drug abuse information and genetic information as well as state laws that often protect the following types of information:1.HIV/AIDS;2. Mental health;3. Genetic tests;4. Alcohol and drug abuse;5. Sexually transmitted diseases and

reproductive health information; and6. Child or adult abuse or neglect,

including sexual assault.If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law. Attached to this notice isaSummaryofFederalandStateLawsonUseandDisclosureofCertainTypesofMedical Information.

25Capital Area

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information onlywithawrittenauthorizationfromyou.Onceyougiveusauthorizationtoreleaseyour health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or “revoke” your written authorizationatanytimeinwriting,exceptif we have already acted based on your authorization.Tofindoutwheretomailyourwrittenauthorizationandhowtorevokeanauthorization,contactthephonenumberlistedonthebackofyourIDcard.

What are your rightsThe following are your rights with respect to your health information:

• Youhavetherighttoasktorestrictuses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies ondependentaccessthatauthorizeyourdependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.

• Youhavetherighttoasktoreceiveconfidential communications of information in a different manner or at a different place (for example, by

sendinginformationtoaP.O.Boxinstead of your home address). We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you. We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing. Mail your request to the address listed below.

• Youhavetherighttoseeandobtainacopy of health information that may be used to make decisions about you such as claims and case or medical management records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information. Mail your request to the address listed below. In certain limited circumstances, we may deny your request to inspect and copy your health information. We may charge a reasonable fee for any copies. If we deny your request, you have the right to have the denial reviewed. If we maintain an electronic health record containing your health information, when and if we are required by law, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify. We may charge a reasonable fee for sending the electronic copy of your health information.

• Youhavetherighttoasktoamendinformation we maintain about you if you believe the health information about you



is wrong or incomplete. Your request must be in writing and provide the reasons for the requested amendment. Mail your request to the address listed below. If we deny your request, you may have a statement of your disagreement added to your health information.

• Youhavetherighttoreceiveanaccounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to youorpursuanttoyourauthorization;and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.

• Youhavetherighttoapapercopyofthis notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice on your health plan website, www.myuhc.com.

exercising your rights• ContactingyourHealthPlan.Ifyou

have any questions about this notice or want to exercise any of your rights, please call the phone number on the back of yourIDcardoryoumaycontacttheUnitedHealth Group Customer Call Center at 866-633-2446.

• SubmittingaWrittenRequest.Mailtous your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

UnitedHealth GroupPSMGPrivacyOfficeMN0006-W008P.O.Box1459Minneapolis, MN 55440

• FilingaComplaint.Ifyoubelieveyourprivacy rights have been violated, you may file a complaint with us at the address listed above.

You may also notify the Secretary of the U.S. DepartmentofHealthandHumanServicesof your complaint. We will not take any action against you for filing a complaint.

27Capital Area

FiNaNCiaL iNForMatioN PriVaCy NotiCeThis notice describes how financial information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Effective January 1, 2011

We2 are committed to maintaining the confidentiality of your personal financial information.Forthepurposesofthisnotice,“personal financial information” means information, other than health information, about an enrollee or an applicant for health care coverage that identifies the individual, is not generally publicly available and is collected from the individual or is obtained in connection with providing health care coverage to the individual.

information We CollectWe collect personal financial information about you from the following sources:

• Informationwereceivefromyouonapplications or other forms, such as name, address, age and social security number; and

• Informationaboutyourtransactionswith us, our affiliates or others, such as premium payment history.

Disclosure of informationWe do not disclose personal financial information about our enrollees or former enrollees to any third party, except as required or permitted by law.

In the course of our general business practices, we may disclose personal financial information about you or others without your permission to our corporate affiliates to provide them with information about your transactions, such as your premium payment history.

Confidentiality and SecurityWe restrict access to personal financial information about you to our employees and service providers who are involved in administering your health care coverage and providing services to you. We maintain physical, electronic and procedural safeguards in compliance with federal standards to guard your personal financial information. We conduct regular audits to guarantee appropriate and secure handling and processing of our enrollees’ information.

your right to access and Correct Personal information If you reside in certain States3, you may have a right to request access to the personal financial information that we record about you. Your right includes the right to know the source of the information and the identity of the persons, institutions, or types of institutions to whom we have disclosed such information within 2 years prior to your request. Your right includes the right to view such information and copy it in person, or request that a copy of it be sent to you by mail (for which we may charge you a reasonable fee to cover our costs). Your right also includes the right to request corrections, amendments or deletions of any information in our possession. The procedures that you must follow to request access to or an amendment of your information are as follows:



• Toobtainaccesstoyourinformation:Submit a request in writing that includes your name, address, social security number, telephone number, and the recorded information to which you would like access. State in the request whether you would like access in person or a copy of the information sent to you by mail. Upon receipt of your request, we will contact you within 30 business days to arrange providing you with access in person or the copies that you have requested.

• Tocorrect,amend,ordeleteanyofyourinformation: Submit a request in writing that includes your name, address, social security number, telephone number, the specific information in dispute, and the identity of the document or record that contains the disputed information. Upon receipt of your request, we will contact you within 30 business days to notify you either that we have made the correction, amendment or deletion, or that we refuse to do so and the reasons for the refusal, which you will have an opportunity to challenge.

Send written requests to access, correct, amend or delete information to:UnitedHealth Group PSMGPrivacyOffice MN0006-W008 P.O.Box1459 Minneapolis, MN 55440

UNiteDHeaLtH groUP HeaLtH PLaN NotiCe oF PriVaCy PraCtiCeS: FeDeraL aND State aMeNDMeNtSRevised: January 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules. There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules. The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and

2. give you a general summary of when we can use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.

29Capital Area

Summary of Federal Laws

Alcohol & Drug Abuse InformationWe are allowed to use and disclose alcohol and drug abuse information that is protected byfederallawonly(1)incertainlimitedcircumstances,and/ordiscloseonly(2)to specific recipients.

Genetic InformationWe are not allowed to use genetic information for underwriting purposes.

Summary of State Laws

General Health Information We are allowed to disclose general health information only (1) undercertainlimitedcircumstances,and/or(2)tospecificrecipients.

CA,NE,RI,VT,WA,WI

HMOsmustgiveenrolleesanopportunitytoapproveorrefuse disclosures, subject to certain exceptions.

KY

You may be able to restrict certain electronic disclosures of such health information.

NV

We are not allowed to use health information for certain purposes.

CA,NH

PrescriptionsWe are allowed to disclose prescription-related information only(1)undercertainlimitedcircumstances,and/or(2)tospecific recipients.

ID,NV

Communicable DiseasesWe are allowed to disclose communicable disease information only(1)undercertainlimitedcircumstances,and/or(2)tospecific recipients.

AZ,IN,MI,OK


NV

Sexually Transmitted Diseases and Reproductive Health

Weareallowedtodisclosesexuallytransmitteddiseaseand/or reproductive health information only (1) under certain limitedcircumstancesand/or(2)tospecificrecipients.

MT, NJ, WA


NV



Alcohol and Drug AbuseWe are allowed to use and disclose alcohol and drug abuse information(1)undercertainlimitedcircumstances,and/ordisclose only (2) to specific recipients.

CT,HI,KY,IL,IN,IA,LA,MD,MA,NH,NV,WA,WI

Disclosures of alcohol and drug abuse information may be restricted by the individual who is the subject of the information.

WA

Genetic InformationWe are not allowed to disclose genetic information without your written consent.

CA,CO,HI,IL,KY,NY,TN

We are allowed to disclose genetic information only (1) under certainlimitedcircumstancesand/or(2)tospecificrecipients.

GA,IA,MD,MA,MO,NV,NH,NM,RI,SC,TX,UT,VT

Restrictionsapplyto(1)theuse,and/or(2)theretentionofgenetic information.

FL,GA,IA,LA,MD,OH,SC,SD,UT,VT

HIV / AIDSWeareallowedtodiscloseHIV/AIDS-relatedinformation only(1)undercertainlimitedcircumstancesand/or(2)tospecific recipients.

AZ,AR,CA,CT,DE,FL,HI,IL, IN, MI, MT, NY, NC, PA, PR,RI,TX,VT,WV

CertainrestrictionsapplytooraldisclosuresofHIV/AIDS-related information.

CT


NV

Mental HealthWe are allowed to disclose mental health information only (1)undercertainlimitedcircumstancesand/or(2)to specific recipients.

CA,CT,DC,HI,IL,IN,KY,MA, MI, PR, WA, WI

Disclosures may be restricted by the individual who is the subject of the information.

WA

Certain restrictions apply to oral disclosures of mental health information.

CT

Certain restrictions apply to the use of mental health information.

ME

Child or Adult AbuseWeareallowedtouseanddisclosechildand/oradultabuseinformationonly(1)undercertainlimitedcircumstances,and/or disclose only (2) to specific recipients.

AL,CO,IL,LA,NE,NJ,NM,RI, TN, TX, UT, WI

You may be able to limit or restrict certain electronic disclosures of such health information.

NV

31Capital Area

1 This Medical Information Notice of Privacy Practices applies to the following health plans thatareaffiliatedwithUnitedHealthGroup:AllSaversInsuranceCompany;AllSaversLifeInsuranceCompanyofCalifornia;AmericanMedicalSecurityLifeInsuranceCompany;AmeriChoiceofConnecticut,Inc.;AmeriChoiceofGeorgia,Inc.;AmeriChoiceofNewJersey,Inc.;AmeriChoiceofPennsylvania,Inc.;ArizonaPhysiciansIPA,Inc.;;DentalBenefitProvidersofCalifornia,Inc.;DentalBenefitProvidersofIllinois,Inc.;EvercareofArizona,Inc.;EvercareofNewMexico,Inc.;EvercareofTexas,LLC;GoldenRuleInsuranceCompany;GreatLakesHealthPlan,Inc.;HealthPlanofNevada,Inc.;MAMSILifeandHealthInsuranceCompany;MD-IndividualPracticeAssocation,Inc.;MidwestSecurityLifeInsuranceCompany;NationalPacificDental,Inc.;NeighborhoodHealthPartnership,Inc.;NevadaPacificDental;OptimumChoice,Inc.;OxfordHealthInsurance,Inc.;OxfordHealthPlans(CT),Inc.;OxfordHealthPlans(NJ),Inc.;OxfordHealthPlans(NY),Inc.;PacifiCareDental;PacifiCareDentalofColorado,Inc.;PacifiCareLifeandHealthInsuranceCompany;PacifiCareLifeAssuranceCompany;PacifiCareofArizona,Inc.;PacifiCareofCalifornia;PacifiCareofColorado,Inc.;PacifiCareofNevada,Inc.;PacifiCareofOklahoma,Inc.;PacifiCareofOregon,Inc.;PacifiCareofTexas,Inc.;PacifiCareofWashington,Inc.;SierraHealth&LifeInsuranceCo.,Inc.;U.S.BehavioralHealthPlan,California;UnimericaInsuranceCompany;UnimericaLifeInsuranceCompanyofNewYork;UnisonFamilyHealthPlanofPennsylvania,Inc.;UnisonHealthPlanofDelaware,Inc.;UnisonHealthPlanofOhio,Inc.;UnisonHealthPlanofPennsylvania,Inc.;UnisonHealthPlanofSouthCarolina,Inc.;UnisonHealthPlanofTennessee,Inc.;UnisonHealthPlanoftheCapitalArea,Inc.;UnitedBehavioralHealth;UnitedHealthcareInsuranceCompany;UnitedHealthcareInsuranceCompanyofIllinois;UnitedHealthcareInsuranceCompanyofNewYork;UnitedHealthcareInsuranceCompanyoftheRiverValley;UnitedHealthcareInsuranceCompanyofOhio;UnitedHealthcareofAlabama,Inc.;UnitedHealthcareofArizona,Inc.;UnitedHealthcareofArkansas,Inc.;UnitedHealthcareofColorado,Inc.;UnitedHealthcareofFlorida,Inc.;UnitedhealthcareofGeorgia,Inc.;UnitedHealthcareofIllinois,Inc.;UnitedHealthcareofKentucky,Ltd.;UnitedhealthcareofLouisiana,Inc.;UnitedHealthcareofMid-Atlantic,Inc.;UnitedHealthcareoftheMidlands,Inc.;UnitedHealthcareoftheMidwest,Inc.;UnitedHealthCareofMississippi,Inc.;UnitedHealthcareofNewEngland,Inc.;UnitedHealthcareofNewYork,Inc.;UnitedHealthcareofNorthCarolina,Inc.;UnitedHealthcareofOhio,Inc.;UnitedHealthcareofTennessee,Inc.;UnitedHealthcareofTexas,Inc.;UnitedhealthcareofUtah,Inc.;UnitedHealthcareofWisconsin,Inc.;UnitedHealthcarePlanoftheRiverValley,Inc.

2 For purposes of this Financial Information Privacy Notice, “we” or “us” refers to the entities listedinfootnote1,beginningonthefirstpageoftheHealthPlanNoticesofPrivacyPractices,plusthefollowingUnitedHealthcareaffiliates:ACNGroupIPAofNewYork,Inc.;ACNGroup,Inc.;AmeriChoiceHealthServices,Inc.;DBPServicesofNewYorkIPA,Inc.;DCGResourceOptions,LLC;DentalBenefitProviders,Inc.;DisabilityConsultingGroup,LLC;HealthAllies,Inc.;MAMSIInsuranceResources,LLC;ManagedPhysicalNetwork,Inc.;MidAtlanticMedicalServices,LLC;OneNetPPO,LLC;OptumHealthBank,Inc.;OxfordBenefitManagement,Inc.;OxfordHealthPlansLLC;PacifiCareHealthPlanAdministrators,Inc.;PacificDentalBenefits,Inc.;ProcessWorks,Inc.;SpecteraofNewYork,IPA,Inc.;UMR,Inc.;UnisonAdministrativeServices,LLC;UnitedBehavioralHealthofNewYorkI.P.A.,Inc.;UnitedHealthCareServices,Inc.;UnitedHealthAdvisors,LLC;UnitedHealthcareServiceLLC;UnitedHealthcareServicesCompanyoftheRiverValley,Inc.;UnitedHealthOneAgency,Inc. This Financial Information Privacy Notice only applies where required by law. Specifically, itdoesnotapplyto(1)healthcareinsuranceproductsofferedinNevadabyHealthPlanofNevada,Inc.andSierraHealthandLifeInsuranceCompany,Inc.;or(2)otherUnitedHealthGrouphealthplansinstatesthatprovideexceptionsforHIPAAcoveredentitiesorhealthinsurance products.

3 California and Massachusetts.



Advance DirectiveA written, legal paper that you sign that lets others know what health care you want, or do not want, if you are very sick or hurt and cannot speak for yourself

Advocate A person who helps you get the health care and other services you need

Amendment A change

Appeal

An appeal is a special kind of complaint you make if you disagree withadecisionUnitedHealthcaremakestodenyarequestforhealth care services or payment for services you already received. You may also make this kind of complaint if you disagree with a decision to stop services that you are receiving

Appointment A certain time and day you and your doctor set aside to meet about your health care needs

Care ManagerSomeonewhoworksforUnitedHealthcareandwillhelpthosepeople in the Disease Management Program get the care and information they need to stay healthy

Check-Up See ScreeningCoercion Making someone do somethingComplaint SeeGrievanceContraception BirthcontrolCovered Services HealthcareservicesthatUnitedHealthcarewillpayfor

Detoxification Gettingridofharmfulsubstancesfromthebodysuchasdrugs and alcohol

Development The way in which your child grows

Disease Management Program

A program to help people with chronic illnesses or special health care needs such as asthma, high blood pressure or mental illness get the care and services they need

Durable Medical Equipment

Special medical equipment that your doctor may ask or tell you to use in your home

Emergency Care Care you need right away for a serious, sudden, sometimes life-threatening condition

EPSDTEarly Periodic Screening, Diagnosis and Treatment Program (also calledHealthCheckProgram)thatgiveshealthcaretomembersunder 21 years old

FairHearing IfyoufileaGrievance/ComplaintyoucanaskforahearingwithD.C.’sOfficeofAdministrativeHearings

Family PlanningServices such as pregnancy tests, birth control, testing and treatmentforsexuallytransmitteddiseases,andHIV/AIDStestingand counseling

What Some Words Mean

33Capital Area

Family and GeneralPracticeDoctor A doctor that can treat the whole family

GrievanceIf you are unhappy with the care you get or the health care servicesUnitedHealthcaregivesyou,youcancallMemberServicestofileaGrievance/Complaint

Handbook ThisbookthatgivesyouinformationaboutUnitedHealthcareandour services

HealthCheckProgram See EPSDTDeaf/hard-of-hearing If you cannot hear well, or if you are deaf

IDEAIndividualswithDisabilitiesEducationAct;afederallawthatgivesservices to children with developmental delays and special health care needs

Immunization Shot, vaccineInternal Medicine Doctor Doctor for adults and children over 14 years old

Interpretation/ Translation Services

HelpfromUnitedHealthcarewhenyouneedtotalktosomeonewho speaks your language, or you need help talking with your doctor or hospital

Managed Care Organization(MCO)

A company that is paid by the District of Columbia to give you health care and health services

Managed Care Plan A plan that gives you a list of providers that you can seeMaternity The time when a woman is pregnantMedicaid Part D A prescription drug benefit paid by Medicare with a small copayMember ThepersonwhogetshealthcarefromUnitedHealthcare

Member Identification Card The card that lets your doctors, hospitals, drug stores, and others knowthatyouareamemberofUnitedHealthcare

MentalHealth Howapersonthinks,feelsandactsindifferentsituations

Network Providers Doctors, nurses, dentists, and other people who take care of your healthwhoareapartofUnitedHealthcare

Non-Covered Services HealthcarethatUnitedHealthcaredoesnotpayfor

OB/GYN Obstetrician/gynecologist;adoctorwhoistrainedtotakecareofawoman’s health, including when she is pregnant

Out-of-NetworkProviders Doctors, nurses, dentists, and other people who take care of your healthwhoarenotapartofUnitedHealthcare

Pediatrician A children's doctorPharmacy The store where you pick up your medicinePhysician Incentive Plan A financial reward for improving a health initiativePost Partum Care Healthcareforawomanaftershehasherbaby

Prenatal Care Care that is given to a pregnant woman the whole time she is pregnant


Prescription Medicinethatyourdoctorordersforyou;youmusttaketheittothepharmacy/drugstoretopickupthemedicine

Preventive Counseling When you want to talk to someone about ways to help you stay healthy or keep you from getting sick or hurt

Primary Care Provider (PCP) The doctor that takes care of you most of the time

Prior Authorization WrittenpermissionfromUnitedHealthcaretogethealthcareortreatmentthatisnotusuallypaidforbyUnitedHealthcare

Provider Directory AlistofallproviderswhoarepartofUnitedHealthcare

Providers Doctors, nurses, dentists, and other people who take care of your health

Retaliation To take revenge or a harmful action

Routine Care

The regular care you get from your primary care provider or a doctor that your primary care provider sends you to. Routine care can be a check-up, physical, health screen, and regular care for health problems like diabetes, asthma and hypertension

ScreeningA test that your doctor or other health care provider may do to see if you are healthy. This could be a hearing test, vision test, or a test to see if your child is developing normally

Seclusion Shutting off

Self-Referral Services Certain services you can get without getting a written note or referral from your main doctor

Services The care you get from your doctor or other health care provider

SpecialHealthCareNeedsChildren and adults who need health care and other services that are more than or different from what other children and adults need

Specialist A doctor who is trained to give a special kind of care like an ear, nose and throat doctor or a foot doctor

Specialty Care Healthcareprovidedbydoctorsornursestrainedtogiveaspecifickind of health care

Sterilization Procedures A surgery you can have if you do not want children in the futureTreatment The care you get from your doctorUrgent Care Care you need within 24 hours, but not right awayVisuallyImpaired If you cannot see well or you are blind

35Capital Area

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37Capital Area

<DMS Code>

This program is funded in part by the Government of the District of Columbia Department of Health Care Finance.

This information is available in other languages and formats by calling Member Services at 1-800-701-7192 (hearing-impaired: 711). • Esta información está disponible en otros idiomas y formatos si llama a servicios para miembros al 1-800-701-7192 (711 para las personas con deficiencias auditivas). • Pour obtenir ces informations dans d’autres langues et formats, veuillez appeler le service des abonnés au 1-800-701-7192 (sourds et mal entendants: 711). • 我们还以其它语言和格式提供了该信息, 您可以致电会员服务部 1-800-701-7192 (有听觉障碍的人士请致电：711) 索取。• Co thê lây thông tin nay băng cac ngôn ngư va hinh thưc khac khi goi sô Dich Vu Thanh Viên tai 1-800-701-7192 (đôi vơi ngươi khiêm thinh: 711). • 회원 서비스 부서 연락처 1-800-701-7192 (청각장애가 있을 경우 711) 로 전화하시면 본 정보를 다른 언어로도 지원받으실 수 있습니다. • ይህ መረጃ በሌሎች ቋንቋዎችና አቀራረቦች ተዘጋጅቶ ይገኛል። እነዚህን ለማግኘት የአባል አገልግሎቶች የስልክ መስመር ጋር 1-800-701-7192 ይደውሉ (መስማት የሚሳናቸው 711 ይደውሉ)።

M49473 8/11 © 2011 United HealthCare Services, Inc .

This program is funded in part by the Government of the District of Columbia Department of Health Care Finance

unitedhealthcare community plan · services at 1-800-701-7192 (tty: 711). a unitedhealthcare...

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