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TennCare Long-Term Services & Supports (LTSS) Frequently Asked Questions

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.

When you apply for Medicaid, you must fill out an application form. You will also need to have various documents:

  • Information about household members (name, date of birth and Social Security number)
  • Rent or mortgage information
  • Expenses (utilities, daycare, etc.)
  • Vehicle information
  • Bank statements
  • Income (pay stubs)
  • Proof of disability or medical records showing a lasting medical condition
  • Recent medical bills
  • Proof of citizenship
  • Additional information as requested

Call 1-800-690-1606. Calls to this number are free. TTY users call 1-800-884-4327. This number requires special telephone equipment. Hours of Operation are from 8 A.M to 5 P.M., Monday – Friday during your time zone.

The Explanation of Benefits is a document you will get each month you use your prescription drug coverage. It will tell you the total amount you have spent on your prescription drugs and the total amount we have paid for your prescription drugs. You will get your Explanation of Benefits in the mail each month that you use the benefits that we provide.

Please call Customer Service at 1-800-690-1606 (Calls to these numbers are free),TTY users call 1-800-884-4327 if there are any changes to your name, address, phone number or changes in health insurance coverage from other sources such as from your employer, spouse’s employer, worker’s compensation, Medicaid, or liability claims such as claims from an automobile accident. Hours of Operation: 8 A.M to 5 P.M., Monday – Friday during your time zone.

You may choose any plan provider to be your PCP. Plan Providers are listed in the provider directory or you may call Customer Service for assistance in finding a plan provider.

 

You may change your PCP for any reason, at any time. Customer Service will help make sure that the PCP you want to switch to is a participating provider with UnitedHealthcare Community Plan for Families. They will also check to be sure the PCP you want to switch to is accepting new patients.

 

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.

You may get care when you are outside the service area. You will usually pay higher costs for the care because you will get your care from non-plan providers, but you won’t pay extra if you are getting care for a medical emergency. If you have questions about your medical costs when you travel, please call Customer Service. Call 1-800-690-1606. Calls to this number are free. TTY users call 1-800-884-4327. This number requires special telephone equipment. Hours of Operation are from 8 A.M to 5 P.M., Monday – Friday during your time zone.

A "medical emergency" is when you reasonably believe that your health is in serious danger – when every second counts. A medical emergency includes severe pain, a bad injury, a serious illness, or a medical condition that is quickly getting much worse.

 

We have network pharmacies outside of the service area where you can get your drugs covered as a member of our Plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Before you fill your prescription in these situations, call Customer Service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for a valid reason, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription.

You may ask us to reimburse you for our share of the cost by submitting a claim form. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay will help you qualify for catastrophic coverage.
Note: If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

When you return home, simply submit your claim and your receipt to the following address:
Prescription Solutions
P.O. Box 6082
Cypress, California 90630-0082

If you submit a paper claim asking us to reimburse you for a prescription drug that is not on our formulary or is subject to coverage requirements or limits, your doctor may need to submit additional documentation supporting your request.

 

A formulary is a list of covered drugs provided by the Plan. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other coverage rules are followed. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage.

The drugs on the formulary are selected by our Plan with the help of a team of health care providers. We select the prescription therapies believed to be a necessary part of a quality treatment program. Both brand-name drugs and generic drugs are included on the formulary. A generic drug has the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs.

Not all drugs are included on the formulary. In some cases, the law prohibits coverage of certain types of drugs. In some cases, we have decided not to include a particular drug.

 

You may call Customer Service to find out if your drug is on the formulary or to request a copy of our formulary. You may also get updated information about the drugs covered by us by visiting our Website.

Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your coinsurance/co-payment depends on which drug tier your drug is in.

If your prescription isn’t listed on the formulary, you should first contact Customer Service to be sure it isn’t covered.

If Customer Service confirms that we don’t cover your drug, you have three options:
You may ask your doctor if you can switch to another drug that is covered by us.

You may ask us to make an exception (which is a type of coverage determination) to cover your drug. See your Evidence of Coverage (member handbook) to learn more about how to request an exception.
You can pay out-of-pocket for the drug and request that the Plan reimburse you by requesting an exception (which is a type of coverage determination). This doesn’t obligate the Plan to reimburse you if the exception request isn’t approved. If the exception isn’t approved, you may appeal the Plan’s denial. Please see your Evidence of Coverage for more information on how to request an appeal.

In some cases, we will contact you if you are taking a drug that isn’t on our formulary. We can give you the names of covered drugs that also are used to treat your condition so you can ask your doctor if any of these drugs are an option for your treatment.

A network pharmacy is a pharmacy that has a contract with us to provide your covered prescription drug. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Once you go to one, you aren’t required to continue going to the same pharmacy to fill your prescription; you may go to any of our network pharmacies.

"Covered drugs" means all of the outpatient prescription drugs that are covered by our Plan. Covered drugs are listed in our formulary.

If you have a medical emergency:

  • Get medical help as quickly as possible. Call 911 for help or go to the nearest emergency room, hospital, or urgent care center. You don’t need to get approval or a referral first from your PCP or other plan provider.
  • 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, usually within 48 hours.

If, while temporarily outside the Plan’s service area, you require urgently needed care, then you may get this care from any provider. The plan is obligated to cover all urgently needed care at the cost-sharing levels that apply to care received within the Plan network.

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

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Medicaid Managed Care

  • Frequently Asked Questions

TN Disclaimer
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If you think you have been treated differently for any of these reasons: Race, Color, National Origin, Disability, Age, Sex, Religion or Any other Status/Group protected by Law, you can file a free online complaint by following the link: https://www.tn.gov/tenncare/members-applicants/civil-rights-compliance.html

Last Updated: 09.19.2024 at 11:35 PM CDT

Disclaimer information
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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.