- Children under age 21
- Foster Care and Adoption Assistance Child under age 21
- Pregnant women including twelve months post delivery
- Infants born to a Medicaid-eligible individual
- FAMIS Children under age nineteen (19)
- Adults
- Under age twenty-six (26) who were formerly in foster care until their discharge from foster care at age eighteen (18) or older.
- Ages nineteen (19) to sixty-four (64) who are parents or caretaker adult relatives with a child under age nineteen (19) (MAGI adults)
- Ages nineteen (19) to sixty-four (64) who are childless (MAGI adults)
What are my rights and responsibilities?
Member rights:
- You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to:
- Be treated fairly and with respect.
- Know that your medical records and discussions with your providers will be kept private and confidential.
- Be told how to choose and change your health plan and your Primary Care Provider.
- Choose any health plan you want that is available in your area and choose your Primary Care Provider from that plan.
- Change your Primary Care Provider.
- Change your health plan without penalty.
- Be told how to change your health plan or your Primary Care Provider.
- Have your provider explain your health care needs to you and talk to you about the different ways your health care problems can be treated.
- Be told why care or services were denied and not given.
- Work as part of a team with your provider in deciding what health care is best for you.
- Say yes or no to the care recommended by your provider.
- Make a complaint to your health plan or to the state Medicaid program about your health care, your provider or your health plan.
- Get a timely answer to your complaint.
- Use the plan’s appeal process and be told how to use it.
- Ask for a fair hearing from the state Medicaid program and get information about how that process works.
- Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need.
- Get medical care in a timely manner.
- Be able to get in and out of a health care provider’s office. This includes barrier free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act.
- Have interpreters, if needed, during appointments with your providers and when talking to your health plan. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information.
- Be given information you can understand about your health plan rules, including the health care services you can get and how to get them.
Member responsibilities:
- You must learn and understand each right you have under the Medicaid program. That includes the responsibility to:
- Learn and understand your rights under the Medicaid program.
- Ask questions if you do not understand your rights.
- Learn what choices of health plans are available in your area.
- Learn and follow your health plan’s rules and Medicaid rules.
- Choose your health plan and a Primary Care Provider quickly.
- Make any changes in your health plan and Primary Care Provider in the ways established by Medicaid and by the health plan.
- Keep your scheduled appointments.
- Cancel appointments in advance when you cannot keep them.
- Always contact your Primary Care Provider first for your non-emergency medical needs.
- Be sure you have approval from your Primary Care Provider before going to a specialist.
- Understand when you should and should not go to the emergency room.
- Tell your Primary Care Provider about your health.
- Talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated.
- Help your providers get your medical records.
- Work as a team with your provider in deciding what health care is best for you.
- Understand how the things you do can affect your health.
- Do the best you can to stay healthy.
- Treat providers and staff with respect.
- Talk to your provider about all of your medications.
If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You can also view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.
How do I file an appeal?
UnitedHealthcare Community Plan will send you a letter if a covered service that you requested is not approved or if payment is denied in whole or in part. If you are not happy with our decision, call UnitedHealthcare Community Plan within 30 days from when you get our letter.
You must appeal within 10 days of the date on the letter to make sure your services are not stopped. You can appeal by sending a letter to UnitedHealthcare Community Plan or by calling UnitedHealthcare Community Plan. You can ask for up to 14 days of extra time for your appeal. UnitedHealthcare Community Plan can take extra time on your appeal if it is better for you. If this happens, UnitedHealthcare Community Plan will tell you in writing the reason for the delay.
You can call Member Services and get help with your appeal. When you call Member Services, we will help you file an appeal. Then we will send you a letter and ask you or someone acting on your behalf to sign a form.
How will I find out if services are denied?
UnitedHealthcare Community Plan will send you a letter if a covered service requested by your PCP is denied, delayed, limited or stopped.
What are the timeframes for the appeal process?
UnitedHealthcare Community Plan has up to 30 calendar days to decide if your request for care is medically needed and covered. We will send you a letter of our decision within 30 days. In some cases you have the right to a decision within one business day. If your provider requests, we must give you a quick decision. You can get a quick decision if your health or ability to function could be seriously hurt by waiting.
When do I have the right to ask for an appeal?
You may request an appeal for denial of payment for services in whole or in part. If you ask for an appeal within 10 days from the time you get the denial notice from the health plan, you have the right to keep getting any service the health plan denied or reduced at least until the final appeal decision is made. If you do not request an appeal within 10 days from the time you get the denial notice, the service the health plan denied will be stopped.
Does my appeal request have to be in writing?
You may request an appeal by phone, but an appeal form will be sent to you, which must be signed and returned. An appeal form will be included in each letter you receive when UnitedHealthcare Community Plan denies a service to you. This form must be signed and returned.
Can someone from UnitedHealthcare Community Plan help me file an appeal?
Member services is available to help you file a complaint or an appeal. You can ask them to help you when you call 1-844-752-9434. They will send you an appeal request form and ask that you return it before your appeal request is taken.
What if I have a complaint?
There are different types of complaints
You can make an internal complaint and/or an external complaint. An internal complaint is filed with and reviewed by UnitedHealthcare Community Plan. An external complaint is filed with and reviewed by an organization that is not affiliated with UnitedHealthcare Community Plan.
Internal complaints
To make an internal complaint, call Member Services at the number below. You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. You can file a complaint in writing, by mailing or faxing it to us at:
Grievance and Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364So that we can best help you, include details on who or what the complaint is about and any information about your complaint. UnitedHealthcare Community Plan will review your complaint and request any additional information. You can call Member Services at the number below if you need help filing a complaint or if you need assistance in another language or format. We will notify you of the outcome of your complaint within a reasonable time, but no later than 30 calendar days after we receive your complaint. If your complaint is related to your request for an expedited appeal, we will respond within 24 hours after the receipt of the complaint.
External complaints
You can file a complaint with the Cardinal Care helpline
You can make a complaint about UnitedHealthcare Community Plan to the Cardinal Care helpline.
Contact the Cardinal Care helpline at 1-844-374-9159 or TDD 1-800-817-6608.
You can file a complaint with the Office for Civil Rights
You can make a complaint to the Department of Health and Human Services’ Office for Civil Rights if you think you have not been treated fairly. For example, you can make a complaint about disability access or language assistance. You can also visit http://www.hhs.gov/ocr for more information.
You may contact the local Office for Civil Rights office at:
Office of Civil Rights- Region III
Department of Health and Human Services
150 S Independence Mall West Suite 372
Public Ledger Building
Philadelphia, PA 19106
1-800-368-1019
Fax: 215-861-4431
TDD: 1-800-537-7697You can file a complaint with the Office of the State Long-Term Care Ombudsman
The State Long-Term Care Ombudsman serves as an advocate for older persons receiving long-term care services. Local Ombudsmen provide older Virginians and their families with information, advocacy, complaint counseling, and assistance in resolving care problems. The State’s Long-Term Care Ombudsman program offers assistance to persons receiving long term care services, whether the care is provided in a nursing facility or assisted living facility, or through community-based services to assist persons still living at home. A Long-Term Care Ombudsman does not work for the facility, the State, or UnitedHealthcare Community Plan. This helps them to be fair and objective in resolving problems and concerns. The program also represents the interests of long-term care consumers before state and federal government agencies and the General Assembly.
The State Long-Term Care Ombudsman can help you if you are having a problem with UnitedHealthcare Community Plan or a nursing facility. The State Long-Term Care Ombudsman is not connected with us or with any insurance company or health plan.
The services are free.
Office of the State Long-Term Care Ombudsman
1-800-464-9950 This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it.
Virginia Office of the State Long-Term Care Ombudsman
Virginia Department for Aging and Rehabilitative Services
8004 Franklin Farms Drive
Henrico, Virginia 23229
804-662-9140
http://www.ElderRightsVA.orgHow do I request a Fair Hearing?
If you disagree with our decision on your appeal request, you can appeal directly to DMAS. This process is known as a State Fair Hearing. You may also submit a request for a State Fair Hearing if we deny payment for covered services or if we do not respond to an appeal request for services within the times described in this handbook. The State requires that you firstexhaust (complete) UnitedHealthcare Community Plan appeals process before you can file an appeal request through the State Fair Hearing process. If we do not respond to your appeal request timely DMAS will count this as an exhausted appeal.
Standard or expedited review requests
For standard requests, appeals will be heard and DMAS will give you an answer generally within 90 days from the date you filed your appeal. If you want your State Fair Hearing to be handled quickly, you must write “EXPEDITED REQUEST” on your appeal request. You must also ask your doctor to send a letter to DMAS that explains why you need an expedited appeal. DMAS will tell you if you qualify for an expedited appeal within 72 hours of receiving the letter from your doctor.
Authorized representative
You can give someone like your PCP, provider, or friend or family Member written permission to help you with your State Fair Hearing request. This person is known as your authorized representative.
Where to send the State Fair Hearing request
You or your representative must send your standard or expedited appeal request to DMAS by internet, mail, fax, email, telephone, in person, or through other commonly available electronic means. Send State Fair Hearing requests to DMAS within no more than 120 calendar days from the date of our final decision. You may be able to appeal after the 120 day deadline in special circumstances with permission from DMAS.
You may write a letter or complete a Virginia Medicaid Appeal Request Form. The form is available at your local Department of Social Services or on the internet at http://www.dmas.virginia.gov/Content_atchs/forms/dmas-200.pdf. You should also send DMAS a copy of the letter we sent to you in response to your Appeal.
You must sign the appeal request and send it to:
Appeals Division
Department of Medical Assistance Services
600 E. Broad Street
Richmond, Virginia 23219
Fax: 804-452-5454Standard and Expedited Appeals may also be made by calling 804-371-8488.
What if my ID card is lost or stolen?
If you lose your/your child’s ID card, call Member Services right away at 1-844-752-9434. Member Services will send you a new one. Call TTY 711 for hearing impaired.
What is a member advisory group?
UnitedHealthcare invites all members to join their Member Advisory Committee. As a member of the committee, you can participate in quarterly educational meetings where you can share you experiences, opinions and hear about how UnitedHealthcare is working to improve the member experience. These meetings can be attend in-person or virtually. Attending committee meetings will give you and your caregiver or family member the chance to provide input on Cardinal Care and meet other members. If you would like more information or want to attend, contact our Member Services department.
Learn more about Cardinal Care
- FAQs
- Glossary
- Links to health information
Enrollment information
UnitedHealthcare Community Plan of Virginia - Cardinal Care plan specialists can answer questions.
Call us:
1-844-752-9434 / TTY: 7118 am to 8 pm, local time, Monday - Friday
You have chosen to enroll in
This plan is not currently available in the ZIP code entered.
Get the details
Visit the Virginia Department of Medical Assistance Services (DMAS) site or on the DMAS' broker site for more information on eligibility and enrollment.
Enrollment information
UnitedHealthcare Community Plan of Virginia - Cardinal Care plan specialists can answer questions.
Call us:
1-844-752-9434 / TTY: 7118 am to 8 pm, local time, Monday - Friday
You have chosen to enroll in
This plan is not currently available in the ZIP code entered.
Get the details
Visit the Virginia Department of Medical Assistance Services (DMAS) site or on the DMAS' broker site for more information on eligibility and enrollment.
Member information
Already a member of UnitedHealthcare Community Plan of Virginia - Cardinal Care? You have access to our member-only website. Print ID cards, chat with a nurse online, and more.
(Opens in new window) PDF 852.27KB - Last Updated: 01/23/2024
(Opens in new window) PDF 1.42MB - Last Updated: 01/23/2024
Member information
Already a member of UnitedHealthcare Community Plan of Virginia - Cardinal Care? You have access to our member-only website. Print ID cards, chat with a nurse online, and more.
(Opens in new window) PDF 852.27KB - Last Updated: 01/23/2024
(Opens in new window) PDF 1.42MB - Last Updated: 01/23/2024
Individual & Family ACA Marketplace Plans Disclaimer (scroll within this box to view)The benefits described may not be offered in all plans or in all states. Some plans may require copayments, deductibles and/or coinsurance for these benefits. This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, review your plan documents, call or write your insurance agent or the company, whichever is applicable. Plan specifics and benefits vary by coverage area and by plan category. Please review plan details to learn more.
UnitedHealthcare Individual & Family plans medical plan coverage offered by: UnitedHealthcare of Arizona, Inc.; Rocky Mountain Health Maintenance Organization Incorporated in CO; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare Insurance Company in AL, KS, LA, MO, NJ, and TN; Optimum Choice, Inc. in MD and VA; UnitedHealthcare Community Plan, Inc. in MI; UnitedHealthcare of Mississippi, Inc.; UnitedHealthcare of New Mexico, Inc.; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of South Carolina, Inc.; UnitedHealthcare of Texas, Inc.; UnitedHealthcare of Oregon, Inc. in WA; and UnitedHealthcare of Wisconsin, Inc. Administrative services provided by United HealthCare Services, Inc. or its affiliates.
This policy has exclusions, limitations, reduction of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company, whichever is applicable. By responding to this offer, you agree that a representative may contact you.
1 Unless otherwise required, benefits are available only when services are delivered through a Designated Virtual Network Provider. Virtual visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times, or in all locations, or for all members. Check your benefit plan to determine if these services are available. Data rates may apply. Certain prescriptions may not be available and other restrictions may apply.
2 Tier 2 prescriptions for $5 or less not available on all medications. 3-month fills apply to select maintenance medications only. Applicable formulary requirements such as prior authorization and quantity limits may apply to your pharmacy benefits. Walgreens discount valid until 12/31/24. Discount valid only for in-store purchases of eligible Walgreens brand health and wellness products by current members eligible for the UnitedHealthcare discount program. Discount cannot be used online. For a full list of Walgreens brand health and wellness products and exclusions, please visit www.walgreens.com/smartsavings.
Last Updated: 08.21.2024 at 10:16 PM CDT
Disclaimer information (scroll within this box to view)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. Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.
Premium disclaimer
Dual Special Needs plans have a $0 premium for members with Extra Help (Low Income Subsidy).
Benefit disclaimer
Benefits, features, and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply.
Nurse Hotline 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 provider'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. Nurse Hotline not for use in emergencies, for informational purposes only.
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.
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® for One Care (Medicare-Medicaid plan)
UnitedHealthcare Connected® for One Care (Medicare-Medicaid plan) is a health plan that contracts with both Medicare and MassHealth (Medicaid) to provide benefits of both programs to enrollees.
UnitedHealthcare Connected® general 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.
UnitedHealthcare Senior Care Options (HMO SNP) plan
UnitedHealthcare Senior Care Options (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 and does not have any other comprehensive health Insurance, except 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 Senior Care Options (SCO) program.
Star ratings disclaimer
Every year, Medicare evaluates plans based on a 5-Star rating system. The 5-Star rating applies to plan year 2024.
Important provider information
The choice is yours
We will provide you with information to help you make informed choices, such as physicians' and health care professionals' credentials. This information, however, is not an endorsement of a particular physician or health care professional's suitability for your needs.
The providers available through this application may not necessarily reflect the full extent of UnitedHealthcare's network of contracted providers. There may be providers or certain specialties that are not included in this application that are part of our network. If you don't find the provider you are searching for, you may contact the provider directly to verify participation status with UnitedHealthcare's network, or contact Customer Care at the toll-free number shown on your UnitedHealthcare ID card. We also recommend that, prior to seeing any physician, including any specialists, you call the physician's office to verify their participation status and availability.
Some network providers may have been added or removed from our network after this directory was updated. We do not guarantee that each provider is still accepting new members.
Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.
American Disabilities Act notice
In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 ("ADA"), UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.
Referrals
Network providers help you and your covered family members get the care needed. Access to specialists may be coordinated by your primary care physician.
Paper directory requests
Paper copies of the network provider directory are available at no cost to members by calling the customer service number on the back of your ID card. Non-members may download and print search results from the online directory.
Inaccurate information
To report incorrect information, email provider_directory_invalid_issues@uhc.com. This email box is for members to report potential inaccuracies for demographic (address, phone, etc.) information in the online or paper directories. Reporting issues via this mail box will result in an outreach to the provider’s office to verify all directory demographic data, which can take approximately 30 days. Individuals can also report potential inaccuracies via phone. UnitedHealthcare Members should call the number on the back of their ID card, and non-UnitedHealthcare members can call 1-888-638-6613 / TTY 711, or use your preferred relay service.
Declaration of disaster or emergency
If you’re affected by a disaster or emergency declaration by the President or a governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, there is certain additional support available to you.
- Part A, Part B, and supplemental Part C plan benefits are to be provided at specified non-contracted facilities (note that Part A and Part B benefits must be obtained at Medicare certified facilities);
- Where applicable, requirements for gatekeeper referrals are waived in full;
- Plan-approved out-of-network cost-sharing to network cost-sharing amounts are temporarily reduced; and
- The 30-day notification requirement to members is waived, as long as all the changes (such as reduction of cost-sharing and waiving authorization) benefit the member.
If CMS hasn’t provided an end date for the disaster or emergency, plans will resume normal operation 30 days after the initial declaration.
