You are eligible for Cardinal Care when you have full Medicaid benefits, and meet one of the following categories:

• You are age 65 and older,
• You are an adult or child with a disability,
• You reside in a nursing facility (NF),
• Individuals who receive services under the 1915(c) Cardinal Care home- and community-based care (HCBS) Waiver
• Aged, blind or disabled (ABD) individuals, including disabled children and adults.
• Managed Care eligible populations who have Medicare (dual-eligible).
• Low-Income Families and Children Covered Populations, including
  • 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)

Member rights:

1. You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to:
   1. Be treated fairly and with respect.
   2. 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:
   1. Be told how to choose and change your health plan and your Primary Care Provider. 
   2. Choose any health plan you want that is available in your area and choose your Primary Care Provider from that plan. 
   3. Change your Primary Care Provider. 
   4. Change your health plan without penalty. 
   5. 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: 
   1. 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.
   2. 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: 
   1. Work as part of a team with your provider in deciding what health care is best for you.
   2. 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:
   1. Make a complaint to your health plan or to the state Medicaid program about your health care, your provider or your health plan.
   2. Get a timely answer to your complaint.
   3. Use the plan’s appeal process and be told how to use it.
   4. 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:
   1. Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need.
   2. Get medical care in a timely manner.
   3. 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.
   4. 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.
   5. 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 you.
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:
   1. Learn and understand your rights under the Medicaid program.
   2. Ask questions if you do not understand your rights.
   3. 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:
   1. Learn and follow your health plan’s rules and Medicaid rules.
   2. Choose your health plan and a Primary Care Provider quickly.
   3. Make any changes in your health plan and Primary Care Provider in the ways established by Medicaid and by the health plan.
   4. Keep your scheduled appointments.
   5. Cancel appointments in advance when you cannot keep them.
   6. Always contact your Primary Care Provider first for your non-emergency medical needs.
   7. Be sure you have approval from your Primary Care Provider before going to a specialist.
   8. 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:
   1. Tell your Primary Care Provider about your health.
   2. Talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated.
   3. 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:
   1. Work as a team with your provider in deciding what health care is best for you.
   2. Understand how the things you do can affect your health.
   3. Do the best you can to stay healthy.
   4. Treat providers and staff with respect.
   5. 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.

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.

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 84131-0364

So 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: 1-800-537-7697

You 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

1-800-552-5019 This call is free.

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.org

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: 804-452-5454

Standard and Expedited Appeals may also be made by calling 804-371-8488.

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.

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.