To qualify for Medicaid, you or your children must:

• Be a Texas resident
• Be a U.S. citizen or a legal resident
• Meet certain resource and income limits
• Fit into one of these groups:
  • Families and children with limited income
  • Children
  • Pregnant women
  • Non-U.S. citizen needing emergency medical services
  • Children or pregnant women who are medically needy due to high medical bills
  • People who get Supplemental Security Income (SSI) from Social Security Administration
  • Persons having low-income and needing long-term services and supports or help with daily activities

There are different ways to apply for Medicaid:

• If you are a person with a disability or a person over 65 years of age with limited income and receive Supplemental Security Income (SSI), you do not have to apply for Medicaid. You will receive Medicaid automatically when you receive SSI. Go to your local Social Security Administration office to apply for SSI.
• Applications for children (age 18 and younger) for CHIP or Children's Medicaid can be done over the phone, by mail, or by fax. You can get an application from the CHIP/Children's Medicaid website at www.chipmedicaid.org, or by calling 1-877-543-7669.
• All other persons must apply for Medicaid through the local HHSC office or a HHSC caseworker in a hospital or clinic.

Your PCP might want you to see a special doctor (specialist) for certain health care needs. While your PCP can take care of most of your health care needs, sometimes they will want you to see a specialist for your care. A specialist has received training and has more experience taking care of certain diseases, illnesses and injuries. UnitedHealthcare Community Plan has many specialists who will work with you and your PCP to care for your needs.

Your PCP will talk to you about your needs and will help make plans for you to see the specialist that can provide the best care for you, including providing a referral if the specialist asks for one. A referral is a special kind of agreement between doctors that says the specialist will treat you. UnitedHealthcare Community Plan does not require referrals for you to see a specialist. You can see any specialist with or without a referral.

You do NOT need a referral for:

• Emergency Services.
• OB/GYN care.
• Behavioral Health Services.
• Routine Vision Services.
• Routine Dental Services.

Contact your PCP or Member Services to determine if you need a referral.

• Pay stubs or other papers to show all family members' monthly income.
• Social Security numbers for all individuals who want Medicaid (not required for children under 6 months of age).
• Papers that show your resources for all individuals who want Medicaid (for example: bank records, make, model, and year of your vehicles). This is not needed if you are applying because you are pregnant or if you are applying only for children (age 18 or younger).
• Legal resident papers if you are not a U.S. citizen and you want Medicaid for yourself.
• Proof of residence (for example: gas, electric, or water bill, letter from your landlord). This is not needed if you are applying only for children (age 18 and younger).
• NOTE: You may ask a friend or other person you choose to be your "authorized representative" to apply for you. You may also ask for a language or a sign interpreter to help you apply. Ask for an interpreter when you call to set up an appointment.

Member Rights:

1. 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.
2. You have the right to a reasonable opportunity to choose a health care plan and Primary Care Provider. This is the doctor or health care provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to:
   • 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.
3. You have the right to ask questions and get answers about anything you do not understand. That includes the right to:
   • 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.
4. You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to:
   •  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. 
5. You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid, and get a timely response to complaints, appeals and fair hearings. That includes the right to:
   • 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.
6. You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to:
   • 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.
7. You have the right to not be restrained or secluded when it is for someone else’s convenience, or is meant to force you to do something you do not want to do, or is to punish yo
8. You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.
9. You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services.
10. You have a right to make recommendations regarding the organization’s member rights and responsibilities policy.

Member Responsibilities:

1. 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.
2. You must abide by the health plan’s and Medicaid’s policies and procedures. That includes the responsibility to:
   • 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.
3. You must share information about your health with your Primary Care Provider and learn about service and treatment options. That includes the responsibility to:
   • 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.
4. You must be involved in decisions relating to service and treatment options, make personal choices, and take action to keep yourself healthy. That includes the responsibility to:
   • 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.

Additional Member Responsibilities while using NEMT Services

1. When requesting NEMT Services, you must provide the information requested by the person arranging or verifying your transportation.
2. You must follow all rules and regulations affecting your NEMT services.
3. You must return unused advanced funds. You must provide proof that you kept your medical appointment prior to receiving future advanced funds.
4. You must not verbally, sexually, or physically abuse or harass anyone while requesting or receiving NEMT services.
5. You must not lose bus tickets or tokens and must return any bus tickets or tokens that you do not use. You must use the bus tickets or tokens only to go to your medical appointment.
6. You must only use NEMT Services to travel to and from your medical appointments.
7. If you have arranged for an NEMT Service but something changes, and you no longer need the service, you must contact the person who helped you arrange your transportation as soon as possible.

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.

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.

What are the time frames 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 by calling 1-888-887-9003. They will send you an appeal request form and ask that you return it before your appeal request is taken.

We want to help:

If you have a complaint, please call us toll-free at 1-888-887-9003 to tell us about your problem. A UnitedHealthcare Community Plan Member Services Advocate can help you file a complaint. Just call 1-888-887-9003. Most of the time, we can help you right away or at the most within a few days.

Who Do I Call?

Call UnitedHealthcare Community Plan Member Services for help at 1-888-887-9003.

Where Can I Mail a Complaint?

For written complaints please send your letter to UnitedHealthcare Community Plan. You must state your name, your member ID number, your telephone number and address, and the reason for your complaint. Please send your letter to:

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
PO Box 31364
Salt Lake City, UT 84131-0364

Once you have gone through the UnitedHealthcare Community Plan complaint process, and are still not satisfied, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free 1-866-566-8989

Filing a complaint with HHSC:

If you receive benefits through Medicaid’s STAR, STAR+PLUS or STAR Kids programs call your medical plan first. If you don’t get the help you need there, you should do one of the following:

• Call Medicaid Managed Care Helpline at 1-866-566-8989 (toll free).
• Online: https://hhs.texas.gov/about-hhs/your-rights/hhs-office-ombudsman
• Mail: Texas Health and Human Services Commission

Office of the Ombudsman, MC H-700
P.O. Box 13247
Austin, TX 78711-3247
Fax: 1-888-780-8099 (toll-free)

Can I ask for a State Fair Hearing?

If you, as a member of the health plan, disagree with the health plan’s internal appeal decision, you have the right to ask for a State Fair Hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A provider may be your representative.

If you want to challenge a decision made by your health plan, you or your representative must ask for the State Fair Hearing within 120 days of the date on the health plan’s letter with the internal appeal decision.

If you do not ask for the State Fair Hearing within 120 days, you may lose your right to a State Fair Hearing. To ask for a State Fair Hearing, you or your representative should call UnitedHealthcare Community Plan at 1-800-288-2160 or send a letter to the health plan at:

UnitedHealthcare Community Plan Attn: Fair Hearings Coordinator 14141 Southwest Freeway, Suite 500 Sugar Land, TX 77478

You have the right to keep getting any service the health plan denied or reduced, based on previously authorized services, at least until the final State Fair Hearing decision is made if you ask for a State Fair Hearing by the later of: (1) 10 calendar days following the date the health plan mailed the internal appeal decision letter, or (2) the day the health plan’s internal appeal decision letter says your service will be reduced or end. If you do not request a State Fair Hearing by this date, the service the health plan denied will be stopped.

If you ask for a State Fair Hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most State Fair Hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied.

HHSC will give you a final decision within 90 days from the date you asked for the State Fair Hearing. If you go through this process, and the services you asked for after appeal and State Fair Hearing is denied, you may have to pay for those services.

If you lose the State Fair Hearing appeal, UnitedHealthcare Community Plan might be able to recover the costs of the service or benefit you received while the appeal was pending. UnitedHealthcare will not recover costs for services you received during the appeal or State Fair Hearing without written permission from HHSC.

If you lose your/your child’s UnitedHealthcare Community Plan ID card, call Member Services right away at 1-888-887-9003. Member Services will send you a new one. Call TDD/TTY 711 for hearing impaired. 

A member advisory group is a group of members that help give suggestions to make the health plan better. If you would like to join the advisory group in your area, call Member Services.