UnitedHealthcare Community Plan Frequently Asked Questions

If you have a medical emergency:

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

A "medical emergency" is a medical problem that you think is so serious that a doctor must treat it right away. Some examples of a medical emergency are severe chest pain, possible stroke, heart attack, or a miscarriage/pregnancy with vaginal bleeding.

If you need urgent care, you can visit an urgent care center. You do not need to get an OK before you do. If you need help locating an urgent care center near you, Member Services can help. If you do not know if you need to visit an urgent care center, you can call your PCP or our 24/7 NurseLine services.

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

Medicare is a federal health insurance program for people who are age 65 or older, disabled persons, or those with end-stage kidney disease. Medicare eligibility is not based on income, and basic coverage is the same in each state.

Our Ohio Medicaid plan covers eligible families, pregnant women of any age, infants, children and young adults Joining a MCP will not cause you to lose your Medicaid, WIC (Women, Infants and Children) or other public assistance benefits. 

Joining UnitedHealthcare Community Plan is voluntary. It is your choice. You also must live in a county that has UnitedHealthcare Community Plan.

Exclusions – Individuals that are not permitted to join a MCP

Individuals are not permitted to join a MCP if they are:

• Dually eligible under both the Medicaid and Medicare programs;
• Institutionalized;
• Eligible for Medicaid by spending down their income or resources to a level that meets the Medicaid program's financial eligibility requirements; or
• Receiving Medicaid Waiver services.
• Additionally, if anyone is a member of a federally recognized Indian tribe they have the option to not be a member of a managed care plan.
• If you believe that you meet any of the above criteria and should not be a member of a managed care plan, or are a member of a federally recognized Indian tribe and do not want to be a member, you must call the Ohio Department of Job and Family Services (ODJFS) Managed Care Enrollment Center at 1-800-324-8680 (TTY 1-800-292-3572).

If you are eligible for Medicaid and would like to enroll with UnitedHealthcare Community Plan, please call the Managed Care Enrollment Center at 1-800-605-3040 (TTY: 1-800-292-3572).

When you apply for Medicaid, you must fill out an application form. You will also need to have various documents. You can get an application for Medicaid by calling the Ohio Medicaid Consumer Hotline at 1-800-324-8680 (TTY: 1-800-292-3572), your local County Department of Job and Family Services office, or click here.

OhioRISE (Ohio Resilience through Integrated Systems and Excellence) is a managed care program that focuses on children and youth with serious behavioral health needs. 

OhioRISE increases access to in-home and community-based services to ensure OhioRISE members and families have help with systems such as juvenile justice, child protection, developmental disabilities, mental health and addiction, education, and others.

An individual who is enrolled in the OhioRISE program will also keep their managed care enrollment for the physical health benefit.

Your PCP is your personal doctor. You may choose any individual physician, physician group practice, advanced practice nurse or advanced practice nurse group practice trained in pediatrics, family medicine (general practice), or internal medicine. If you are pregnant, you can choose a PCP trained in obstetrics/gynecology (OB/GYN). Plan Providers are listed in the provider directory or you may call Member Services for assistance in finding a plan provider.

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

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

It is important to remember that you must receive services covered by UnitedHealthcare Community Plan from UnitedHealthcare Community Plan facilities and/or providers. The only time you can see providers that are not on UnitedHealthcare Community Plan's panel is for:

• Emergency services
• Federally Qualified Health Centers / Rural Health Clinics
• Qualified Family Planning Providers
• Community Mental Health Centers
• Ohio Department of Alcohol and Drug Addiction Services facilities that are Medicaid providers
• An out of panel provider that UnitedHealthcare Community Plan has approved you to see
• Pharmacies for prescription drugs and some prescription medical supplies that are covered by Ohio Medicaid

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

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

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

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

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

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

You may get up to a one month supply of your medications. Most drug orders may be refilled when most (85%) of it has been used. For example, if your doctor prescribes you one pill a day, you would be able to get your refill every fourth week. The pharmacy will not be able to refill a prescription earlier. Some drugs may be limited to the amount that can be prescribed in a month.

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

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

There are a few reasons this could happen.

1. Some covered drugs need prior authorization.
2. Some drugs are called Step Therapy medications. That means you need to try other drugs before this one. These are covered only after other first-line drugs have been tried and failed.
3. Some drugs may be limited to the amount a person can be prescribed in one month.
4. Sometimes, a different strength or type of medicine is covered, such as tablets or liquid.

If you need other drugs, your doctor must get Prior Authorization from UnitedHealthcare Community Plan. Your doctor has to state how long you have been taking the drug and what other drugs you have tried.

Drugs

If your doctor wants you to have a drug that is not on our list, your doctor can request it. Our pharmacy staff looks over the request within 24 hours and makes a decision.

• If you need drugs right away, the pharmacist can fill a one-time, five-day supply of the drugs not on our Preferred Drug List.
• If you take the drug on an ongoing basis, the pharmacist can fill a 15-day supply. The pharmacist will have to call UnitedHealthcare Community Plan's pharmacy department for approval.

In some cases your provider must get permission from the health plan before giving you a certain service. This is called prior authorization. This is your provider’s responsibility. If they do not get prior authorization, you will not be able to get those services.