Consumer's right to know about health plans in Massachusetts

Visit myuhc.com to find information on network doctors and other health care professionals who can meet your need for primary care, specialty care or behavioral health care, if applicable. Information on network hospitals and other health care facilities can also be found here.

Always confirm the network participation of both the health care professional and the facility before receiving health care services. Some plans do not provide benefit coverage for care received outside the network. Check your plan coverage before selecting a physician or hospital.

The UnitedHealth Premium^® designation makes it easy for you to find doctors who meet national standards for quality and local market benchmarks for cost efficiency¹.  That way, you can review your options and choose a doctor with confidence. You can find a doctor's Premium designation on myuhc.com. For more information about why choosing a quality doctor and hospital is important, visit United Health Premium Program.

We also provide information from the NCQA Physician Recognition Program. The program highlights superior performance and practice for doctors in three areas of care: diabetes, cardiac and stroke. NCQA is an independent, nonprofit organization that has developed these programs in association with the American Diabetes Association^®, American Heart Association^® and the American Stroke Association^®. These doctors are designated with the NCQA emblem in our online directory.

Your health insurance coverage may be canceled or refused for renewal only in the following circumstances:

• Failure by you or another responsible party to make the payments required under your contract;
• Misrepresentation or fraud by you;
• Commission of acts of physical or verbal abuse by you which pose a threat to providers or other insureds of UnitedHealthcare and which are unrelated to your physical or mental condition. The procedure to be used for this type of disenrollment must be prescribed or approved by the Massachusetts Commissioner of Insurance;
• Your relocation outside the service area of UnitedHealthcare or;
• Non-renewal or cancellation of the group contract through which you receive coverage.

UnitedHealthcare implements a robust Quality Improvement (QI) program which continuously monitors, assesses and evaluates the quality, accessibility, availability and appropriateness of care and service.

The program’s goal is to evaluate the care provided to enrollees to help them achieve improved health and well-being. The program strives to act on identified opportunities for improvement in quality of service and clinical care to ensure optimal outcomes. It promotes and incorporates quality into the health plan’s organizational structure and processes. The QI department coordinates UnitedHealthcare sub-committees, risk management and patient safety activities.

The health plan uses the Quality Improvement Quality of Care and Quality of Service reports to identify health plan care and service issues.  The health plan’s Northeast Regional Peer Review Committee reviews Quality of Care and Quality of Service Reports quarterly.

UnitedHealthcare is accredited through the National Committee for Quality Assurance (NCQA), a nationally recognized accreditation organization. The QI program establishes standards and guidelines in line with NCQA accreditation that encompass all health plan quality improvement activities. The QI program is responsive to Consumer Assessment of Health plan Survey (CAHPS), Providers and Systems surveys and maintains compliance with local, state and Federal regulatory requirements and accreditation standards.

The program facilitates a partnership between customers, practitioners, providers and healthplan staff and works towards the continuous improvement of quality health care delivery through improved communication and education. It facilitates the achievement of public health goals through health promotion, early detection and treatment.  Examples of QI Program interventions include:

• Reminder programs for Immunizations, Mammography, Cervical Cancer Screening, Diabetic Comprehensive and Cardiac Care.
• Toll-free numbers, personalized web sites, and educational resources to answer member questions and concerns 24 hours a day.
• Wellness promotion and health management education.

Coverage decisions are based on benefit design and Certificates of Coverage. The determination of “medical necessity” is between the member and his or her provider. Although the physician may determine a service or procedure to be “medically necessary”, all claims submitted are assessed based on covered services outlined in your Certificate of Coverage. Requests for services not covered in the Certificate of Coverage will result in non-payment of claims.  Members do have the right to appeal.

Concurrent review processes address the appropriateness of an admission, continued stay setting and level of care as well as identify and prevent delays in care, clinical coverage decisions and discharge planning.

An adverse determination as the result of a concurrent or prospective medical review will:

• specify whether or not you have any liability;
• occur only after a medical director has contacted and discussed the case with the ordering physician or designee (or made a reasonable attempt to contact);
• be given to you and your provider in writing; and
• will include appeal rights always be issued by a medical director.

Some medical practices and treatments are not yet proven effective. New practices, treatments, tests and technologies are reviewed nationally by the Medical Technology Assessment Unit of UnitedHealthcare. Doctors and researchers in this unit research medical and scientific material about the topic and prepare an assessment and coverage recommendation. This information is reviewed by a Committee of UnitedHealthcare doctors, nurses, pharmacists and guest experts who make the final coverage decision.

If you have a question about the status or outcome of a coverage decision made in Care Coordination, please call the toll-free member phone number on your health plan ID card.

UnitedHealthcare Insurance Company utilizes the Central Escalation Unit (CEU) health plan reports to identify service issues specific to the UnitedHealthcare Insurance Company plan population.  UnitedHealthcare Insurance Company Quality Oversight Committee (QOC) reviews CEU complaint and appeal reports quarterly.

As a member, you may make an inquiry or complaint regarding UnitedHealthcare benefits, coverage, services, operations, policies and providers by calling the Customer Service Center number on the back of your membership card. A complaint or appeal request may be initiated in a written or verbal format.

Complaints or requests for appeal (grievances) that are made verbally, will be reduced to writing by UnitedHealthcare, and a copy will be sent to you within forty-eight (48) hours of receipt, unless this time limit is waived or extended by you and UnitedHealthcare by mutual written agreement. For grievances submitted in writing or electronically, we will send you a written acknowledgment within 15 days of receipt. For all grievances, we will send you a written resolution within 30 days of receipt. A complaint or appeal must be initiated either by the enrollee or an authorized representative acting on behalf of an enrollee with the enrollee’s written consent when applicable. If proper authorization is not received, the complaint or appeal will not be processed.

Where expedited review of grievances is available for urgent situations, your grievance will be resolved prior to your discharge from a hospital for inpatient stays or within 48 hours from our receipt of a physician’s certification of an urgent need for durable medical equipment.

If you have a terminal illness and submit a grievance, the grievance will be resolved within 5 business days of receipt, except that grievances regarding urgently needed services for such insureds shall be resolved within 72 hours. If the denial of benefits is upheld, you may request conference to review this information. The conference will be scheduled within 10 days of your request.

You may appeal a health plan decision regarding denial of claim, services or service payment by calling or writing to UnitedHealthcare using the phone number or address noted on the denial letter or “Explanation of Benefits.” Except as stated above, if you appeal a denial, we will send you a written acknowledgment within 15 days of receipt and send you a written resolution within 30 days of receipt.

If you are not satisfied with UnitedHealthcare’s final decision regarding an adverse determination, and all health plan internal appeals have been exhausted, you may request an external review within 4 months of receipt of UnitedHealthcare’s written notice of the final adverse determination with a 45 day resolution time.

If your plan requires you to select a primary care physician, in the event of disenrollment of your primary care physician for reasons other than those related to quality or fraud, UnitedHealthcare will provide you with written notice of your primary care physician’s disenrollment at least thirty (30) days prior to the disenrollment. In this notice, you will be instructed to call your Customer Service Center for assistance in selecting a new primary care physician.

You will be permitted to continue to receive care from your primary care physician for at least 30 days following the disenrollment.  If you are in your second or third trimester of pregnancy and your OB provider is involuntarily disenrolled from UnitedHealthcare for reasons other than those related to quality or fraud, you may continue treatment with your OB provider for a period up to, and including, your first postpartum visit.

For terminally ill members, if the treating provider is involuntarily disenrolled for reasons other than those related to quality or fraud, treatment with that provider may continue until the member’s death.

If you are newly insured by UnitedHealthcare, and you are receiving care from a physician who is not in UnitedHealthcare’s network, you will be able to continue receiving services from this physician for up to thirty (30) days from your effective date of coverage. If you are in your second or third trimester of pregnancy, you may continue to receive care through your first postpartum visit. Terminally ill members may continue care until death. These continuation provisions apply only if:

• your employer only offers you a choice of insurance carriers in which your physician is not a participating provider; and
• your physician is providing you with an ongoing course of treatment or is your primary care physician

All of the above continuation of care provisions are conditional upon the provider’s agreeing:

• to accept reimbursement from UnitedHealthcare at the rates applicable prior to the notice of disenrollment as payment in full;
• to not impose cost sharing to you in an amount that would exceed the cost sharing that could have been imposed if the provider had not been disenrolled;
• to adhere to the quality assurance standards of UnitedHealthcare and to provide UnitedHealthcare with necessary medical information related to care provided; and,
• to adhere to UnitedHealthcare policies and procedures, including procedures regarding referral, obtaining prior authorization and providing treatment pursuant to a treatment plan, if any, approved by UnitedHealthcare.

If your plan requires you to select a primary care physician UnitedHealthcare will allow your primary care physician to authorize a standing referral for specialty health care provided by a health care provider participating in UnitedHealthcare’s network when:

• the primary care physician determines that such referrals are appropriate;
• the provider of specialty health care agrees to a treatment plan for you and provides your primary care physician with all necessary clinical and administrative information on a regular basis; and
• the health care services to be provided are consistent with the terms of your Certificate of Coverage.

UnitedHealthcare does not require you to obtain a referral or prior authorization from your primary care physician for the following specialty care provided by an obstetrician, gynecologist, certified nurse-midwife or family practitioner participating in UnitedHealthcare’s provider network:

• annual preventive gynecologic health examinations, including any subsequent, obstetric or gynecological services determined by the obstetrician, gynecologist, certified nurse-midwife or family practitioner to be medically necessary as a result of such examination
• maternity care
• medically necessary evaluations and resultant health care services for acute or emergency gynecological conditions

UnitedHealthcare does not require higher copayments, coinsurance, deductibles or additional cost sharing for these services in the absence of a referral from your primary care physician.

Certain Prescription Drug Products for which Benefits are described under this Prescription Drug Rider are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You or your prescribing health care provider may request an exception to step therapy requirements through the Prior Authorization process. An exception to step therapy requirements will be granted if any of the following apply:

• The prescription drug required under the step therapy protocol is contraindicated or will likely cause an adverse reaction or physical or mental harm.
• The prescription drug required under the step therapy protocol is expected to be ineffective, based on both of the following:
  • Your known clinical characteristics; and
  • The known characteristics of the prescription drug regimen;
•  You or your prescribing health care provider have provided documentation establishing that you have previously:
  • Tried the prescription drug required under the step therapy protocol or another prescription drug in the same pharmacologic class or with the same mechanism of action; and
  • Such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event; or
• You or your prescribing health care provider have provided documentation establishing that:
  • You are stable on the requested prescription drug prescribed by your health care provider; and
  • Switching drugs will likely cause an adverse reaction or physical or mental harm.

We will notify you and your prescribing health care provider of our determination for a step therapy review within three (3) business days for non-urgent care situations or within 24 hours for urgent care situations after receiving a request. Any denial notice of a step therapy request will include a detailed, written explanation of the reason for the denial and the clinical rationale supporting the denial.

Upon request, you will be allowed a 30-day fill of a covered medication, on which you have already been prescribed and are stable, while the step therapy exception request is being reviewed.

You may find out whether a Prescription Drug Product is subject to step therapy requirements by contacting us at www.myuhc.com or the telephone number on your ID card.

Decisions as to whether your benefit plan will pay for any portion of the cost of a health care service you intend to receive or have received—are made according to the coverage terms, benefits, limitations and exclusions as provided in your benefit plan documents.

Some services may require a formal review to determine if benefit coverage is in accordance with the benefit plan offering. In addition, some services may require you to notify UnitedHealthcare, or get approval from UnitedHealthcare, prior to receiving the service, in order to receive benefit coverage. This may involve a Clinical Coverage Review (CCR) which includes a review of clinical records to determine if benefit coverage for requested services in accordance with applicable benefit plan documents, state insurance laws, and state and federal mandates, as required.

UnitedHealthcare has guidelines and policies in place for the development, approval and availability of Clinical Review Criteria that include:

• UnitedHealthcare Clinical Services Medical Management (UCSMM) uses external and internal clinical review criteria that are evaluated annually by the quality oversight committee and approved by the medical director or equivalent designee.
• External clinical review criteria are based on applicable state/federal law, contract or government program requirements, or the adoption of evidence-based clinical practice guidelines such as MCG Care Guidelines or InterQual.
• Internal clinical review criteria are developed by UnitedHealthcare (UHC) through review of current, new and emerging medical technologies.

All clinical non-coverage determinations are made by physicians. Notice of all review outcomes is communicated in accordance with applicable state, federal or accreditation requirements. If you have questions or concerns about how a benefit coverage decision was determined, call the member phone number on your health plan ID card.

If you need covered health care services that are not available from a network provider—or access to a network provider would require unreasonable delay or travel—you or your doctor can ask for a referral to an out-of-network provider. 

To request a referral to an out-of-network provider, call the toll-free member phone number on your health plan ID card; for mental health and substance use disorder services, call the Mental Health phone number on your ID card. If you wish to have someone else represent you for this request, please tell us and we will send you the form needed to designate a representative. 

UnitedHealthcare provides coverage of pediatric specialty care, including mental health care, by persons with recognized expertise in providing specialty pediatrics to members requiring such services.

Physician profiling information for physicians licensed to practice in Massachusetts is available from the Massachusetts Board of Registration in Medicine.

UnitedHealthcare provides members, upon request, interpreter and translation services related to administrative procedures. These services are generally provided through the AT&T language service.

The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities.

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the member toll-free phone number listed on your ID card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

請注意：如果您說中文(Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。

The state of Massachusetts defines a medical emergency as “a medical condition, whether physical, behavioral, related to substance use disorder, or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health the insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in §1867(e)(1)(B) of the Social Security Act, 42 U.S.C. §1395dd(e)(1)(B).”

If you have a medical emergency, you should call 911 or go to the nearest hospital emergency room. UnitedHealthcare does not discourage you from using the 911 system or your local equivalent. If you do go to a hospital emergency room, please call our Customer Services Department as soon as it is reasonable or ask the emergency attending physician to notify your primary care provider.

You will not be denied coverage for medical and transportation expenses incurred as a result of an emergency medical condition.

With the implementation of the new law, Massachusetts has established an Office of Patient Protection (OPP). Staff in this office are available to answer questions or assist you if you are not satisfied with a response you have received from UnitedHealthcare. The toll-free telephone number for the Office of Patient Protection is 1-800-436-7757, the Internet site is Mass, and email address is hpc-opp@state.ma.us.

In addition, The OPP collects and posts certain information reported by health insurance companies who offer insurance plans in Massachusetts. Information, such as network physician termination rates, the number of grievance denials and approvals and claims data can be found at Office of Patient Protection.

We hope this information about the new managed care law in Massachusetts and your health plan is helpful to you. Additional information about your health care and coverage is available from your Certificate of Coverage, member handbook and from the UnitedHealthcare web site for Members, myuhc.com. Your Certificate of Coverage is the controlling document for determining coverage. Questions about this letter or other questions about your plan should be directed to Customer Service using the telephone number on the back of your membership card.

For the year 2016, the voluntary and involuntary disenrollment rate (as defined under 211 CMR 52.13) for UnitedHealthcare Insurance Company was 0%.