UnitedHealthcare Community Plan
Medicaid
2023 Certificate of Coverage (COC)
UnitedHealthcare Community Plan
3000 Town Center
Suite 1400
Southfield, Mi 48075
1-800-903-5253
CSMI23MD0113891_000
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Medicaid Certificate of Coverage (COC)
Article I: General conditions ............. 6
1.1 Certificate ........................ 6
1.2 Rights and Responsibilities ........... 6
1.3 Execution of Certificate .............. 6
1.4 Waiver by UnitedHealthcare
Community Plan, Amendments ....... 6
1.5 Assignment ....................... 6
Article II: Definitions ................... 7
2.1 Applicability ...................... 7
2.2 Application ....................... 7
2.3 UnitedHealthcare Community Plan ..... 7
2.4 Certificate ........................ 7
2.5 Copayment ....................... 7
2.6 Cosmetic Surgery .................. 7
2.7 Covered Services .................. 7
2.8 Department ....................... 7
2.9 DIFS ............................ 7
2.10 Emergency Services ................ 7
2.11 Experimental, Investigational or
Research Medical, Surgical or
Other Health Care Drug, Device,
Treatment or Procedure ............. 8
2.12 Family Planning Services ............ 8
2.13 Health Professional ................. 8
2.14 Hospice Services .................. 8
2.15 Hospital .......................... 8
2.16 Hospital Services .................. 8
2.17 Long-Term Care Facility ............. 8
2.18 Medicaid Agreement ................ 8
2.19 Medicaid Program ................. 8
2.20 Medical Director ................... 8
2.21 Medically Necessary ................ 9
2.22 Medicare ......................... 9
2.23 Member .......................... 9
2.24 Member Agreement ................ 9
2.25 Non-Covered Services .............. 9
2.26 Non-Participating Provider ........... 9
2.27 Participating Hospital ............... 9
2.28 Participating Physician .............. 9
2.29 Participating Provider ............... 9
2.30 Physician ......................... 9
2.31 Premium ......................... 9
2.32 Primary Care Provider (PCP) .......... 9
2.33 Service Area ...................... 9
2.34 Specialist Provider ................. 9
2.35 Urgent Care ....................... 9
Table of contents
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Medicaid Certificate of Coverage (COC)
Article III: Eligibility ...................10
3.1 Member Eligibility ................. 10
3.2 Effective Date of Eligibility ........... 10
3.3 Newborn Eligibility. ................ 10
3.4 Children’s Special Health Care
Services (CSHCS) ................. 10
3.5 Final Determination ................ 10
Article IV: Enrollment ..................11
4.1 Newborns ....................... 11
4.2 Change of Residency .............. 11
Article V: Effective date of coverage. . . . . . 11
5.1 Effective Dates of Enrollment ........ 11
5.2 Notification ...................... 11
Article VI: Relationship with providers ....11
6.1 Choosing a Primary Care
Provider (PCP) ................... 11
6.2 Role of Primary Care Provider. . . . . . . . 11
6.3 Changing a Primary Care Provider .... 12
6.4 Specialist Physicians and
Other Participating Providers ........ 12
6.5 Self-Referral to Participating
Providers Without Authorization ...... 12
6.6 Non-Participating Providers ......... 13
6.7 Independent Contractors ........... 13
6.8 Termination of Provider’s
Participation ..................... 13
6.9 Inability to Have a Provider-Patient
Relationship ..................... 14
6.10 Refusal to Follow Provider’s Orders ... 14
Article VII: Members rights
and responsibilities ...................14
7.1 Release and Confidentiality of
Member Medical Records .......... 14
7.2 Member Complaints, Grievances
and Appeals ..................... 23
7.3 Member Identification (ID) Cards ..... 24
7.4 Forms and Questionnaires .......... 24
7.5 UnitedHealthcare Community Plan
Board of Directors ................. 24
7.6 Non-Covered Services ............. 24
7.7 Regular Communication ............ 24
7.8 Your Rights as a Member ........... 24
7.9 UnitedHealthcare Community Plan
Policies and Procedures ............ 24
7.10 Continuity of Care ................. 24
7.11 Pain Medicine .................... 24
Article VIII: Payment for
covered services .....................25
8.1 Periodic Premium Payments ......... 25
8.2 Members Covered ................ 25
8.3 Copayments ..................... 25
8.4 Claims .......................... 25
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Medicaid Certificate of Coverage (COC)
Article IX: Covered services ............26
9.1 Member eligibility ................. 26
9.2 Covered services ................. 26
Article X: Emergency or urgent care
in the service area ....................33
10.1 Emergency Services ............... 33
10.2 Urgent Care ...................... 33
Article XI: Out-of-area services ..........33
11.1 Covered Services ................. 33
11.2 Hospitalization. . . . . . . . . . . . . . . . . . . . 33
Article XII: Exclusions and limitations ....34
12.1 Exclusions ....................... 34
12.2 Limitations ....................... 35
Article XIII: Term and termination ........36
13.1 Term ........................... 36
13.2 Termination of Certificate ........... 36
13.3 Termination of Enrollment ........... 36
13.4 Disenrollment by Member ........... 37
Article XIV: Coordination of benefits .....37
14.1 Purpose ......................... 37
14.2 Assignment ...................... 37
14.3 Claims .......................... 37
14.4 Order of Benefits .................. 38
14.5 UnitedHealthcare Community Plan
Rights .......................... 38
14.6 Construction ..................... 38
Article XV: Subrogation ................38
15.1 Assignment; Suit .................. 38
15.2 Definition ........................ 38
Article XVI: Miscellaneous ..............39
16.1 Governing Law ................... 39
16.2 Contract ........................ 39
16.3 Period of Time for Legal Claims ...... 39
16.4 Policies and Procedures ............ 39
16.5 Notice .......................... 39
16.6 Headings ........................ 39
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Medicaid Certificate of Coverage (COC)
Article I: General conditions
1.1 Certificate. This is the Certificate of Coverage (Certificate) for the Medicaid Program
recipients who have enrolled in UnitedHealthcare Community Plan, Inc. (UnitedHealthcare
Community Plan). This is for members in the Medicaid program. The terms and conditions
of this certificate follow the compiled laws of the State of Michigan and Medicaid.
UnitedHealthcare Community Plan must provide these benefits. The benefits are
required to uphold a Medicaid Agreement with the State of Michigan. By enrolling in
UnitedHealthcare Community Plan, the Member agrees to follow the terms and conditions
of this Certificate.
1.2 Rights and Responsibilities. This Certificate defines the rights and obligations of Members
and UnitedHealthcare Community Plan. It is the Member’s responsibility to understand this
Certificate. Section 9.2 of this Certificate lists the Covered Services. Members are entitled
to service under the terms and conditions of this Certificate. Some medical services,
equipment, and supplies are not covered. Some service needs prior authorization by
UnitedHealthcare Community Plan. Members have a responsibility to understand the
rights of Members. These are listed in the Member Handbook.
1.3 Execution of Certificate. Members agree that submitting a Member Application makes
them subject to the rules of this Certificate. By accepting this Certificate, Members are
entering into an agreement with UnitedHealthcare Community Plan. That Member
agreement includes: the Application, the Certificate, the Member Handbook and the
Plan ID cards.
1.4 Waiver by UnitedHealthcare Community Plan, Amendments. Only officers of
UnitedHealthcare Community Plan have authority to waive any conditions of this
Certificate. That includes timing of payment, and exchange of information. All
changes to this Certificate must be in writing. Changes are signed by an officer of
UnitedHealthcare Community Plan. Changes are approved by the Department of
Insurance and Financial Services.
1.5 Assignment. All rights of a Member to get Covered Services under the Member Agreement
are personal. They may not be assigned to any other person or entity. Any attempts to
reassign rights of the Member Agreement may result in termination of coverage.
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Medicaid Certificate of Coverage (COC)
Article II: Definitions
2.1 Applicability. Article II defines words to clarify understanding for Members. These
definitions apply to this certificate and any changes or additions while it is in effect.
2.2 Application means the Member Application form which a Medicaid recipient must
complete and sign. The Application begins eligibility process and enrollment in the State
of Michigan Medical Assistance Program. The Michigan Department of Health and Human
Services manages this program.
2.3 UnitedHealthcare Community Plan is a for-profit corporation. It operates as a health
maintenance organization under the authority of the State of Michigan’s Department of
Insurance and Financial Services (DIFS).
2.4 Certificate. This means this contract or Member Agreement between UnitedHealthcare
Community Plan and Members. This includes all amendments, addenda, appendices
and riders.
2.5 Copayment. This means the amount a Member may have to pay directly to a Provider for
some services. These are listed in Article IX.
2.6 Cosmetic Surgery. This means procedures which improve physical appearance, but which
do not improve a physical function, and are not Medically Necessary.
2.7 Covered Services. This means the Medically Necessary services, equipment and supplies
listed in Section 9.2. These are subject to the terms of this Certificate. UnitedHealthcare
Community Plan must follow the service guidelines in the Medicaid Agreement.
2.8 Department. This term shortens the Michigan Department of Health and Human Services
or its successor. This agency administers the Medicaid Program in the State of Michigan.
This agency monitors the health maintenance organizations, like UnitedHealthcare
Community Plan for the State.
2.9 DIFS. The letters stand for Department of Insurance and Financial Services or its
successor. This agency monitors the health maintenance organizations like
UnitedHealthcare Community Plan for the State.
2.10 Emergency Services. These are services needed to treat an emergency medical condition.
This means a condition with serious symptoms. This includes severe pain. It means that
without fast medical care, a person would think (i) jeopardy to the person’s health or the
health of an unborn child; (ii) serious harm to bodily functions; or (iii) dysfunction of any
body organ or part.
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Medicaid Certificate of Coverage (COC)
2.11 Experimental, Investigational or Research Medical, Surgical or Other Health Care
Drug, Device, Treatment or Procedure. This means a drug, device, treatment that meets
at least one of the following conditions that make it an experimental procedure: It cannot
be lawfully marketed without the approval of the Food and Drug Administration (FDA) and
approval has not been granted at the time of its use. It is the part of a current new drug or
new device application on file with the FDA. It is part of a Phase I or Phase II clinical trial.
This includes a research arm of a Phase III clinical trial. It is being provided with the
objective of determining safety, efficiency in comparison to existing treatments. It is
described as experimental in nature by patient information documents. It is subject to the
approval of an Institutional Review Board (IRB) as needed by federal regulations. Rules
of the FDA, the Department of Health and Human Services (HSS), or a human subjects
committee is most important. It is experimental if medical experts deem it so. That expert
opinion can be published medical journals. That opinion can warn of more information to
determine safety and effectiveness. At the time of use, it is not generally accepted by the
medical community. Coverage for drugs used in antineoplastic therapy is covered pursuant
to MCL §500.3406e of the Michigan Insurance Code.
2.12 Family Planning Services. These are services to prevent pregnancy or treat sexually
transmitted diseases. This includes medically approved evaluations, drugs, supplies,
devices, or counseling.
2.13 Health Professional. This is a health care provider who is qualified to give health services
under Michigan law.
2.14 Hospice Services. This means support services for the terminally ill and their families.
They must be from a licensed or Medicare certified Hospice. They are mainly for pain relief
and to manage symptoms. The services may be in the home or a facility setting.
2 .15 Ho spi t al. This means a care facility licensed as a hospital by the State of Michigan.
It provides inpatient medical care. It has medical, diagnostic, and surgical facilities.
2.16 Hospital Services. These are those Covered Services which are provided by a Hospital.
2.17 Long-Term Care Facility. This facility is licensed by the Department to give inpatient
nursing care.
2.18 Medicaid Agreement. This is a contract between the State of Michigan and
UnitedHealthcare Community Plan. It states that UnitedHealthcare Community Plan agrees
to the administration of Covered Services for Members.
2.19 Medicaid Program. Name for the Department’s program for Medical Assistance. This is set
forth in Section 105 of Public Act 280 of 1939, as amended, MCL 400.105, and Title XIX of
the Federal Social Security Act, 42. U.S.C. 1396 et seq., as amended.
2.20 Medical Director. This is a Physician chosen by UnitedHealthcare Community Plan to
oversee the medical aspects of UnitedHealthcare Community Plan services.
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Medicaid Certificate of Coverage (COC)
2.21 Medically Necessary. Covered Services from a provider that is needed to identify, treat or
avoid an illness or injury. This is determined by UnitedHealthcare Community Plan Medical
Director or UnitedHealthcare Community Plan Utilization Management representative. For
approval of payment the following are considered: The service must match the symptoms,
diagnosis and treatment of Member’s condition. The service meets the standards of
medical practice. The service is not a matter of convenience. The service is safely provided
to Member. Not all Medically Necessary services are Covered Services.
2.22 Medicare. A program under Title XVIII of the Federal Social Security Act, 42 U.S.C.
1395 et seq.
2.23 Member. This person is a Medicaid recipient enrolled in UnitedHealthcare Community Plan.
The Department has paid a Premium for service to be given to this person.
2.24 Member Agreement. The understanding of responsibility between the Member and
UnitedHealthcare Community Plan as presented in this Certificate, the Member’s
Application, the Member Handbook, and the UnitedHealthcare Community Plan ID Card.
2.25 Non-Covered Services. Health care services, equipment and supplies which are not
Covered Services.
2.26 Non-Participating Provider. Provider or Hospital that has not contracted with
UnitedHealthcare Community Plan to provide Covered services to Members.
2.27 Participating Hospital. Hospital that contracts with UnitedHealthcare Community Plan
to provide Covered services.
2.28 Participating Physician. Doctor who contracts with UnitedHealthcare Community Plan
to provide Covered Services.
2.29 Participating Provider. Any Health Provider or Hospital that contracts with
UnitedHealthcare Community Plan to provide Covered Services.
2.30 Physician. Doctor of Medicine (MD) or Doctor of Osteopathy (DO) licensed in the State
of Michigan.
2.31 Premium. Money prepaid by the Department for Members to get Covered Services.
2.32 Primary Care Provider (PCP) is the Participating Provider who is responsible for
coordinating the care of their patients who are members.
2.33 Service Area means the areas in which UnitedHealthcare Community Plan is allowed by
DIFS and MDHHS to provide services.
2.34 Specialist Provider. Participating Provider, other than a PCP, who provides services with
referral. These services may need prior approval by UnitedHealthcare Community Plan.
2.35 Urgent Care. The care needs to be given right away. The condition or illness does not
risk health of person, or unborn baby. The condition or illness does not risk body or organ
dysfunction means services that are not Emergency Services, but are required right away.
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Medicaid Certificate of Coverage (COC)
Article III: Eligibility
3.1 Member Eligibility. To enroll in UnitedHealthcare Community Plan a person must:
A. Be eligible for the Medicaid Program which is done by the Department of Health and
Human Services; and
B. Live in the Service Area.
3.2 Effective Date of Eligibility. If a Member becomes eligible during a month, he or she is
eligible for the whole month. In some cases, covered services used before Member knows
eligibility may be covered. Actual eligibility occurs on the first day of the month after the
Member is determined eligible. (This does not apply to newborns.) UnitedHealthcare
Community Plan is not responsible for paying for health care services before the date of
enrollment, except for newborns. (Refer to ll-G6.) If the Member is an inpatient in a hospital
on the date of enrollment (first day of the month), UnitedHealthcare Community Plan will not
be responsible for the inpatient stay or any charges prior to discharge. UnitedHealthcare
Community Plan will be responsible for all care from the date of discharge forward.
If a Member is disenrolled from UnitedHealthcare Community Plan while in a hospital,
UnitedHealthcare Community Plan will cover all charges until the date of discharge.
3.3 Newborn Eligibility. Newborns of Members who were enrolled at the time of the child’s
birth will be enrolled with UnitedHealthcare Community Plan.
3.4 Children’s Special Health Care Services (CSHCS). These are health care and case
management services for Members eligible for Michigan Medicaid — Children’s Special
Health Care Services (CSHCS).
CSHCS is a state of Michigan program that serves children and some adults with special
health care needs. CSHCS covers more than 2,700 medical diagnoses.
3.5 Final Determination. In all cases, the Department shall make the final decision on eligibility.
The Department makes the final decision about enrollment status in UnitedHealthcare
Community Plan.
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Medicaid Certificate of Coverage (COC)
Article IV: Enrollment
4.1 N ew bo rn s. A Member’s newborn child is enrolled in UnitedHealthcare Community Plan
from the date of birth. UnitedHealthcare Community Plan must notify the Department
of the birth of the newborn. The birth notice must be within the guidelines of the
Medicaid Agreement.
4.2 Change of Residency. A Member must notify the Department and UnitedHealthcare
Community Plan when the Member moves outside of the Service Area. The Member
will be able to get Covered Services until he or she is disenrolled from UnitedHealthcare
Community Plan.
Article V: Effective date of coverage
5.1 Effective Dates of Enrollment. A Member’s enrollment in UnitedHealthcare
Community Plan and coverage will be effective on the date determined by the
Department and UnitedHealthcare Community Plan Guidelines for effective date are
in the Medicaid Agreement.
5.2 Notification. UnitedHealthcare Community Plan will notify a Member of the effective date
of coverage.
Article VI: Relationship with providers
6.1 Choosing a Primary Care Provider (PCP). Each Member must select a Primary Care
Provider. If the Member is a minor or cannot choose a PCP, the adult responsible for the
Member must choose their PCP. UnitedHealthcare Community Plan may choose a PCP
for the Member if he or she does not choose one within thirty (30) days of joining
UnitedHealthcare Community Plan. UnitedHealthcare Community Plan may also choose
a PCP if the contract between UnitedHealthcare Community Plan and the PCP is revoked.
If a provider is no longer the Member’s PCP, is assigned by mistake or will not provide
medical services, UnitedHealthcare Community Plan may choose another PCP.
6.2 Role of Primary Care Provider. The Member’s PCP provides or manages the Member’s
health care services along with UnitedHealthcare Community Plan. This includes
referrals to Specialists, ordering lab tests and X-rays, prescribing medicines or therapies,
and arranging hospital stays. The PCP generally coordinates a Member’s medical care
as appropriate.
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Medicaid Certificate of Coverage (COC)
6.3 Changing a Primary Care Provider. A Member may change his or her PCP by contacting
UnitedHealthcare Community Plan Customer Service. All changes must be approved in
advance by the Customer Service Department. They will notify the Member of the effective
date of the change.
6.4 Specialist Physicians and Other Participating Providers. Members must get referrals
from their PCP. In some cases these services need authorization from UnitedHealthcare
Community Plan. In the event that a Participating Provider is not available, UnitedHealthcare
Community Plan will consider approving another provider.
6.5 Self-Referral to Participating Providers without Authorization. If a Member does not
get a PCP referral or prior approval from UnitedHealthcare Community Plan, he or she may
have to pay for services. This does not include Emergency Services. A Member may only
get medically necessary services without a referral from a PCP for:
A. Well woman care from a participating OB/GYN.
B. Certified Nurse Midwife Services.
C. Certified pediatric and family nurse practitioner services.
D. Family Planning from any family planning clinic.
E. Immunizations from the Health Department.
F. Pediatrician visits made by a child under the age of eighteen (18) to any participating
pediatrician.
G. Vision services from any participating optometrist.
H. Chiropractic care visits from any participating chiropractor for up to eighteen (18) visits
every calendar year for subluxation of the spine.
I. Non-emergency transportation or gas reimbursement from a UnitedHealthcare
Community Plan transportation provider.
J. Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), Child and
Adolescent Health Centers (CAHCs), Tribal Health Centers (THCs). Members may
go to any FQHC, RHC, CAHC, or THC without being sent by their PCP even if it is not
a UnitedHealthcare Community Plan provider. They will not have an extra copay.
K. Behavioral health care from any participating behavioral health provider or at any
Federally Qualified Health Center (FQHC), Rural Health Center (RHC), Child and
Adolescent Health Center (CAHC) or Tribal Health Center (THC).
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Medicaid Certificate of Coverage (COC)
6.6 Non-Participating Providers. Members do not have to pay for Covered Services from
Non-Participating Providers, if:
A. The provider has not informed the Member in writing that the services are not covered
by UnitedHealthcare Community Plan;
B. The provider did not get prior approval from UnitedHealthcare Community Plan. Or the
provider did not submit a claim to UnitedHealthcare Community Plan within one (1) year
of the date of service; and
C. There is a difference between the provider’s charge and the UnitedHealthcare
Community Plan payment.
6.7 Independent Contractors. UnitedHealthcare Community Plan does not directly provide
any health care service under this Agreement. UnitedHealthcare Community Plan arranges
Covered Services for Members. Providers are solely responsible for medical judgments.
UnitedHealthcare Community Plan is solely responsible for benefit determinations. All
decisions follow the Member Agreement and the Medicaid Agreement and contracts with
Participating Providers. It disclaims any right or responsibility to make medical decisions.
Such decisions may only be made by Providers in consultation with the Member. A Provider
and a Member may elect to continue treatments despite UnitedHealthcare Community Plan
denial of coverage. Members may appeal any of UnitedHealthcare Community Plan benefit
decisions. There is a Grievance and Appeal process for Members.
6.8 Termination of Provider’s Participation. UnitedHealthcare Community Plan or a Provider
may terminate their contract or limit the number of Members that the Provider will accept.
UnitedHealthcare Community Plan does not promise that a Provider will be able to render
services. If a Member’s PCP no longer acts as a PCP, the Member must choose another
PCP. If a Provider is no longer a Participating Provider, the Member must work with his or
her PCP to pick another.
To make sure care a Member started can be finished, UnitedHealthcare Community
Plan will work with the Member’s doctor. The Member can continue treatment for up to
90 days if:
• A new member is in an ongoing course of care with a non-UnitedHealthcare Community
Plan provider
• UnitedHealthcare Community Plan ends a contract with a provider for reason other
than cause
• A Member who is less than 13 weeks pregnant must see a UnitedHealthcare
Community Plan provider for all her care
• A Member who is over 13 weeks pregnant can continue to see her current OB/GYN
provider until the end of postpartum care
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Medicaid Certificate of Coverage (COC)
6.9 Inability to Have a Provider-Patient Relationship. If a Member is unable to have a good
relationship with a PCP or a Specialist, UnitedHealthcare Community Plan may:
A. Ask the Member to pick another PCP; or
B. Arrange to have the Member’s PCP refer the Member to another Specialist; or
C. Allow Member’s disenrollment, meeting the guidelines of the Medicaid Agreement.
6.10 Refusal to Follow Provider’s Orders. A Member may refuse to follow a Provider’s orders.
The Provider may then ask the Member to pick another Provider.
The Member may ask the Medical Director to arrange a second opinion. The Medical
Director will resolve any disagreement between the first and second opinions from another
Provider. The Member must pay for any medical services, equipment or supplies not
ordered by the first Provider:
A. If the Member refuses to follow a Provider’s orders.
B. If the Member does not request a second opinion.
C. If the second Provider agrees that there is no alternate treatment.
Article VII: Members’ rights and responsibilities
7.1 Release and Confidentiality of Member Medical Records.
7.1.1 Member’s medical information and personal health information (PHI) must be kept private
by UnitedHealthcare Community Plan. It shall not be shared with third parties without the
prior written consent of the Member. See exceptions in the UnitedHealthcare Community
Plan Notice of Privacy Practices.
7.1. 2 The Member’s signature on the Medicaid Application gives UnitedHealthcare Community
Plan the right to get medical information from providers. This information exchange
follows the Medicaid Agreement, Member Agreement and state and federal laws.
7.1.3 Each Member authorizes providers to share PHI with medical records with
UnitedHealthcare Community Plan. Each Member agrees to provide health history.
Each Member agrees to help get prior medical records when needed; the Member
authorizes release of his or her medical records.
7.1.4 Members may request to look at their own medical records per state and federal law.
The review will be done at the Provider’s offices during business hours.
7.1.5 UnitedHealthcare Community Plan Privacy Notice.
Privacy Practices Notice for Medical Information
Privacy Practices Notice for Financial Information
Member Rights and Responsibilities
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Medicaid Certificate of Coverage (COC)
Health Plan Notices of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.
Effective January 1, 2023
By law, we
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must protect the privacy of your health information (“HI”). We must send you this notice.
It tells you:
• How we may use your HI.
• When we can share your HI with others.
• What rights you have to access your HI.
By law, we must follow the terms of this notice.
HI is information about your health or health care services. We have the right to change our privacy
practices for handling HI. If we change them, we will notify you by mail or e-mail. We will also post
the new notice at this website (www.uhccommunityplan.com). We will notify you of a breach of your
HI. We collect and keep your HI to run our business. HI may be oral, written or electronic. We limit
employee and service provider access to your HI. We have safeguards in place to protect your HI.
How we collect, use, and share your information
We collect, use, and share your HI with:
• You or your legal representative.
• Government agencies.
We have the right to collect, use and share your HI for certain purposes. This must be for your
treatment, to pay for your care, or to run our business. We may use and share your HI as follows.
• For Payment. We may collect, use, and share your HI to process premium payments and
claims. This may include coordinating benefits.
• For Treatment or Managing Care. We may collect, use, and share your HI with your providers
to help with your care.
• For Health Care Operations. We may suggest a disease management or wellness program.
We may study data to improve our services.
• To Tell You about Health Programs or Products. We may tell you about other treatments,
products, and services. These activities may be limited by law.
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Medicaid Certificate of Coverage (COC)
• For Plan Sponsors. We may give enrollment, disenrollment, and summary HI to your employer.
We may give them other HI if they properly limit its use.
• For Underwriting Purposes. We may collect, use, and share your HI to make underwriting
decisions. We will not use your genetic HI for underwriting purposes.
• For Reminders on Benefits or Care. We may collect, use and share your HI to send you
appointment reminders and information about your health benefits.
• For Communications to You. We may use the phone number or email you gave us to contact
you about your benefits, healthcare or payments.
We may collect, use, and share your HI as follows:
• As Required by Law.
• To Persons Involved with Your Care. This may be to a family member in an emergency. This
may happen if you are unable to agree or object. If you are unable to object, we will use our best
judgment. If permitted, after you pass away, we may share HI with family members or friends
who helped with your care.
• For Public Health Activities. This may be to prevent disease outbreaks.
• For Reporting Abuse, Neglect or Domestic Violence. We may only share with entities allowed
by law to get this HI. This may be a social or protective service agency.
• For Health Oversight Activities to an agency allowed by the law to get the HI. This may be for
licensure, audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings. To answer a court order or subpoena.
• For Law Enforcement. To find a missing person or report a crime.
• For Threats to Health or Safety. This may be to public health agencies or law enforcement.
An example is in an emergency or disaster.
• For Government Functions. This may be for military and veteran use, national security, or the
protective services.
• For Workers’ Compensation. To comply with labor laws.
• For Research. To study disease or disability.
• To Give Information on Decedents. This may be to a coroner or medical examiner. To identify
the deceased, find a cause of death, or as stated by law. We may give HI to funeral directors.
• For Organ Transplant. To help get, store or transplant organs, eyes or tissue.
• To Correctional Institutions or Law Enforcement. For persons in custody: (1) to give health
care; (2) to protect your health and the health of others; and (3) for the security of the institution.
• To Our Business Associates if needed to give you services. Our associates agree to protect
your HI. They are not allowed to use HI other than as allowed by our contract with them.
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Medicaid Certificate of Coverage (COC)
• Other Restrictions. Federal and state laws may further limit our use of the HI listed below.
We will follow stricter laws that apply.
1. Alcohol and Substance Abuse
2. Biometric Information
3. Child or Adult Abuse or Neglect, including Sexual Assault
4. Communicable Diseases
5. Genetic Information
6. HIV/AIDS
7. Mental Health
8. Minors’ Information
9. Prescriptions
10. Reproductive Health
11. Sexually Transmitted Diseases
We will only use your HI as described here or with your written consent. We will get your written
consent to share psychotherapy notes about you. We will get your written consent to sell your HI to
other people. We will get your written consent to use your HI in certain promotional mailings. If you let
us share your HI, the recipient may further share it. You may take back your consent. To find out how,
call the phone number on your ID card.
Your rights
You have the following rights.
• To ask us to limit use or sharing for treatment, payment, or health care operations. You can ask
to limit sharing with family members or others. We may allow your dependents to ask for limits.
We will try to honor your request, but we do not have to do so.
• To ask to get confidential communications in a different way or place. For example, at a
P.O. Box instead of your home. We will agree to your request as allowed by state and federal law.
We take verbal requests. You can change your request. This must be in writing. Mail it to
the address below.
• To see or get a copy of certain HI. You must ask in writing. Mail it to the address below. If we
keep these records in electronic form, you can request an electronic copy. You can have your
record sent to a third party. We may send you a summary. We may charge for copies. We may
deny your request. If we deny your request, you may have the denial reviewed.
• To ask to amend. If you think your HI is wrong or incomplete you can ask to change it. You must
ask in writing. You must give the reasons for the change. Mail this to the address below. If we
deny your request, you may add your disagreement to your HI.
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Medicaid Certificate of Coverage (COC)
• To get an accounting of HI shared in the six years prior to your request. This will not include
any HI shared for the following reasons. (i) For treatment, payment, and health care operations;
(ii) With you or with your consent; (iii) With correctional institutions or law enforcement. This will
not list the disclosures that federal law does not require us to track.
• To get a paper copy of this notice. You may ask for a paper copy at any time. You may also get
a copy at our website (www.uhccommunityplan.com).
• To ask that we correct or amend your HI. Depending on where you live, you can also ask us to
delete your HI. If we can’t, we will tell you. If we can’t, you can write us, noting why you disagree
and send us the correct information.
Using your rights
• To Contact your Health Plan. Call the phone number on your ID card. Or you may contact the
UnitedHealth Group Call Center at 1-866-633-2446, or TTY/RTT 711.
• To Submit a Written Request. Mail to:
UnitedHealthcare Privacy Office
MN017-E300, P.O. Box 1459, Minneapolis MN 55440
• Timing. We will respond to your phone or written request within 30 days.
• To File a Complaint. If you think your privacy rights have been violated, you may send a
complaint at the address above.
You may also notify the Secretary of the U.S. Department of Health and Human Services. We will
not take any action against you for filing a complaint.
1
This Medical Information Notice of Privacy Practices applies to the following health plans that are
affiliated with UnitedHealth Group: AmeriChoice of New Jersey, Inc.; Arizona Physicians IPA, Inc.;
Care Improvement Plus South Central Insurance Company; Care Improvement Plus of Texas
Insurance Company; Care Improvement Plus Wisconsin Insurance; Health Plan of Nevada, Inc.;
Optimum Choice, Inc.; Oxford Health Plans (NJ), Inc.; Physicians Health Choice of Texas, LLC;
Preferred Care Partners, Inc.; Rocky Mountain Health Maintenance Organization, Incorporated;
UnitedHealthcare Benefits of Texas, Inc.; UnitedHealthcare Community Plan of California, Inc.;
UnitedHealthcare Community Plan of Ohio, Inc.; UnitedHealthcare Community Plan of Texas,
L.L.C.; UnitedHealthcare Community Plan, Inc.; UnitedHealthcare Community Plan of Georgia,
Inc.; UnitedHealthcare Insurance Company; UnitedHealthcare Insurance Company of America;
UnitedHealthcare Insurance Company of River Valley; UnitedHealthcare of Alabama, Inc.;
UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Kentucky, Ltd.; UnitedHealthcare of
Louisiana, Inc.; UnitedHealthcare of the Mid-Atlantic, Inc.; UnitedHealthcare of the Midlands, Inc.;
UnitedHealthcare of the Midwest, Inc.; United Healthcare of Mississippi, Inc.; UnitedHealthcare of
New England, Inc.; UnitedHealthcare of New Mexico, Inc.; UnitedHealthcare of New York, Inc.;
UnitedHealthcare of Pennsylvania, Inc.; UnitedHealthcare of Washington, Inc.; UnitedHealthcare
of Wisconsin, Inc.; and UnitedHealthcare Plan of the River Valley, Inc. This list of health plans is
complete as of the effective date of this notice. For a current list of health plans subject to this notice
go to https://www.uhc.com/privacy/entities-fn-v2.
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Financial Information Privacy Notice
THIS NOTICE SAYS HOW YOUR FINANCIAL INFORMATION MAY BE USED AND SHARED.
REVIEW IT CAREFULLY.
Effective January 1, 2023
We
2
protect your “personal financial information” (“FI”). FI is non-health information. FI identifies you
and is generally not public.
Information we collect
• We get FI from your applications or forms. This may be name, address, age and social
security number.
• We get FI from your transactions with us or others. This may be premium payment data.
Sharing of FI
We will only share FI as permitted by law.
We may share your FI to run our business. We may share your FI with our Affiliates. We do not need
your consent to do so.
• We may share your FI to process transactions.
• We may share your FI to maintain your account(s).
• We may share your FI to respond to court orders and legal investigations.
• We may share your FI with companies that prepare our marketing materials.
Confidentiality and security
We limit employee and service provider access to your FI. We have safeguards in place to protect
your FI.
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Medicaid Certificate of Coverage (COC)
Questions about this notice
Please call the toll-free member phone number on health plan ID card or contact the UnitedHealth
Group Customer Call Center at 1-866-633-2446, or TTY/RTT 711.
2
For purposes of this Financial Information Privacy Notice, “we” or “us” refers to the entities listed
in footnote 1, beginning on the last page of the Health Plan Notices of Privacy Practices, plus the
following UnitedHealthcare affiliates: ACN Group of California, Inc.; AmeriChoice Corporation.;
Benefitter Insurance Solutions, Inc.; Claims Management Systems, Inc.; Dental Benefit Providers,
Inc.; Ear Professional International Corporation; Excelsior Insurance Brokerage, Inc.;
gethealthinsurance.com Agency, Inc. Golden Outlook, Inc.; Golden Rule Insurance Company;
HealthMarkets Insurance Agency; Healthplex of CT, Inc.; Healthplex of ME, Inc.; Healthplex of NC,
Inc.; Healthplex, Inc.; HealthSCOPE Benefits, Inc.; International Healthcare Services, Inc.; Level2
Health IPA, LLC; Level2 Health Management, LLC; Life Print Health, Inc.; Managed Physical
Network, Inc.; Optum Care Networks, Inc.; Optum Global Solutions (India) Private Limited; Optum
Health Care Solutions, Inc.; Oxford Benefit Management, Inc.; Oxford Health Plans LLC; Physician
Alliance of the Rockies, LLC; POMCO Network, Inc.; POMCO, Inc.; Real Appeal, LLC; Solstice
Administrators of Alabama, Inc.; Solstice Administrators of Arizona, Inc.; Solstice Administrators of
Missouri, Inc.; Solstice Administrators of North Carolina, Inc.; Solstice Administrators of Texas, Inc.;
Solstice Administrators, Inc.; Solstice Benefit Services, Inc.; Solstice of Minnesota, Inc.; Solstice of
New York, Inc.; Spectera, Inc.; Three Rivers Holdings, Inc.; U.S. Behavioral Health Plan, California;
UHIC Holdings, Inc.; UMR, Inc.; United Behavioral Health; United Behavioral Health of New York
I.P.A., Inc.; UnitedHealthcare, Inc.; United HealthCare Services, Inc.; UnitedHealth Advisors, LLC;
UnitedHealthcare Service LLC; Urgent Care MSO, LLC; USHEALTH Administrators, LLC; and
USHEALTH Group, Inc.; and Vivify Health, Inc. This Financial Information Privacy Notice only
applies where required by law. Specifically, it does not apply to (1) health care insurance products
offered in Nevada by Health Plan of Nevada, Inc. and Sierra Health and Life Insurance Company,
Inc.; or (2) other UnitedHealth Group health plans in states that provide exceptions. This list of
health plans is complete as of the effective date of this notice. For a current list of health plans
subject to this notice go to https://www.uhc.com/privacy/entities-fn-v2.
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Medicaid Certificate of Coverage (COC)
Member rights and responsibilities
Your rights
• To be treated with respect no matter what your race, religion, color, age, sex, health condition,
familial status, height, weight, disability or veteran’s status
• To get information about all health services and be explained how to obtain services
• To choose a doctor from our list of UnitedHealthcare Community Plan Primary Care
Providers (PCPs)
• To file a grievance, to request a fair hearing or have an external review under the Patient’s Right
to Independent Review Act
• To voice grievances or appeals about UnitedHealthcare Community Plan or the care it provides
• To make suggestions about UnitedHealthcare Community Plan’s member rights and
responsibilities policies
• To have your medical records and communications kept private
• To expect UnitedHealthcare Community Plan staff and providers to comply with all
member rights
• To get full information from your PCP or provider about any treatment or test that may be needed
for your health care
• To participate in decisions on your health care
• To accept or refuse treatment
• To discuss medically necessary treatment options, regardless of cost or coverage
• To get information about UnitedHealthcare Community Plan. Information is about services,
business, and health care providers, and providers.
• To ask if UnitedHealthcare Community Plan has special financial arrangements with providers
that can affect the use of referrals and services. Call UnitedHealthcare Community Plan to get
this information.
• To see any UnitedHealthcare Community Plan OB/GYN for well-woman exams or obstetrical
care without a referral from your PCP
• To see any UnitedHealthcare Community Plan pediatrician if you are under the age of 18 without
a referral from your PCP
• To get a copy of these rights and responsibilities. To have them explained to you if you have
any questions.
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Medicaid Certificate of Coverage (COC)
Your responsibilities
• To be an informed member. Read your Member Handbook and call UnitedHealthcare
Community Plan if you have any questions.
• To understand your health problems. To take part in setting health and treatment goals.
• To call UnitedHealthcare Community Plan for approval of all hospitalizations, except for
emergencies or for urgent care
• To tell UnitedHealthcare Community Plan of any other health insurance you have
• To tell your PCP your full health history. To tell the truth about any changes in your health.
To give the information that UnitedHealthcare Community Plan and its providers need to
provide care.
• To listen and follow your PCP’s advice for care you have agreed on. To help them plan what
treatment will work best for you.
• To know the names of your medications. To know what they are for and how to use them.
• To report any emergency care within 48 hours to your PCP. Report an emergency stay at a
hospital soon after.
• To always carry your UnitedHealthcare Community Plan ID card
• To respect the rights of other patients, doctors, office staff and staff at UnitedHealthcare
Community Plan
• To tell UnitedHealthcare Community Plan if you move or change phone numbers. To tell
us about changes that affect your health, like childbirth. Call customer service and keep
us informed.
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Medicaid Certificate of Coverage (COC)
7.2 Member Complaints, Grievances and Appeals. UnitedHealthcare Community Plan has
procedures for processing and resolving Member complaints, grievances, and appeals.
Those relating to the benefits or the operation of UnitedHealthcare Community Plan must
follow MCL 500.3541 and Michigan’s Independent Review Act. The Member Complaint,
Grievance and Appeal Procedure is described in the Member Handbook. Complaints,
Grievances and Appeals not settled through this procedure may be appealed to the
Department of Insurance and Financial Services (DIFS), Office of General Counsel –
Appeals Section, by mail, P.O. Box 30220 Lansing, MI 48909-7720, by courier/delivery, 530
W. Allegan Street, 7th Floor, Lansing, MI 48933, Fax: 517-284-8838, Phone: 1-877-999-6442.
DIFS has an online option for External Review at https://difs.state.mi.us/Complaints/
ExternalReview.aspx.
Members must exhaust UnitedHealthcare Community Plan Member Complaint, Grievance
Procedure before asking DIFS for review. Members must submit the request for DIFS review
within 127 calendar days of the adverse decision. The exception is if a Member could
seriously jeopardize life, health or function because of the expedited internal appeal time
frame. Such condition must be confirmed by a doctor orally or in writing.
Members also have the right to request a fair hearing with the Michigan Department of
Health and Human Services Law tribunal. Members must exhaust UnitedHealthcare
Community Plan Member, Complaint, Grievance Procedure before requesting a fair hearing
with the MDHHS Law Tribunal. The request must be submitted within 120 calendar days
of the adverse decision. Mail the form sent with the denial notice to: Michigan Hearings
System for the Michigan Department of Health and Human Services, P.O. Box 30763,
Lansing, Ml 48909-7695, phone 1-877-833-0870.
In conducting the review, the Resolving Analyst (RA) must review the Member’s governing
plan documents, Handbooks and as applicable the state Medicaid contract, the previous
adverse benefit determination and follows as documented on the CSA Member Appeals
and Grievances processing grid.
1. The RA must apply the terms of the governing plan documents, unless a specific
regulatory requirement applies, or the case requires a clinician’s review of medical
necessity or clinical criteria to determine applicability of coverage.
2. The RA is responsible for communicating the appeal decision to the member
in writing after the completion of the review, in accordance with applicable
regulatory requirements.
Members can request a member handbook by phone or writing to Customer Service
(1-800-903- 5253) or can access an online version at myuhc.com/communityplan. The
Handbook describes the Complaint, Appeals and Grievance Procedure. They may get more
copies at any time.
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Medicaid Certificate of Coverage (COC)
7.3 Member Identification (ID) Cards.
7.3.1 UnitedHealthcare Community Plan will issue a UnitedHealthcare Community Plan ID card
to each Member. A Member should present his or her UnitedHealthcare Community Plan
ID card to a Provider each time the Member gets services.
7.3.2 If a Member lets another person use his or her UnitedHealthcare Community Plan ID card,
UnitedHealthcare Community Plan may reclaim Plan ID card. It may terminate the Member’s
enrollment. It may terminate the enrollment of all Members in the Member’s household.
7.3.3 If a Member knows that his or her UnitedHealthcare Community Plan ID card is lost or
stolen, the Member must notify UnitedHealthcare Community Plan Customer Service by the
end of the next business day.
7.4 Forms and Questionnaires. Members must complete any UnitedHealthcare Community
Plan medical questionnaires and other forms. Members warrant that all information in them
is true and complete to the best of their knowledge.
7.5 UnitedHealthcare Community Plan Board of Directors. At least one third of
UnitedHealthcare Community Plan Board of Directors must be Members elected by
Members. Members may ask for a list of UnitedHealthcare Community Plan Board of
Directors showing the enrollee board members. Changes in board membership are listed in
the UnitedHealthcare Community Plan newsletter. Members may contact UnitedHealthcare
Community Plan about becoming a member of the Board of Directors.
7.6 Non-Covered Services. Members must pay for of all Non-Covered Services if they agree
to this in writing before the service is given. Non-Covered Services from Participating
Providers can also be Member’s responsibility.
7.7 Regular Communication. Members will get a UnitedHealthcare Community Plan
newsletter. It tells about policy, policy changes, and how best to use UnitedHealthcare
Community Plan services.
7.8 Your Rights as a Member. Each Member has rights as required by law. Details on rights
are in the Member Handbook.
7.9 UnitedHealthcare Community Plan Policies and Procedures. Members must read and
comply with the terms of the Member Agreement.
7.10 Continuity of Care. Each Member may continue treatment if the Primary Care Provider’s
participation ends during the course of the treatment. This is subject to the limitations set
forth in MCL 500.2212b.
7.11 Pain Medicine. Each Member may ask for information on the credentials of providers.
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Medicaid Certificate of Coverage (COC)
Article VIII: Payment for covered services
8.1 Periodic Premium Payments. The Department or its agent will pay UnitedHealthcare
Community Plan, on behalf of each Member, the Premiums specified in the Medicaid
Agreement. These will be paid on or before their due dates.
8.2 Members Covered. Members for whom the Premium has been received by
UnitedHealthcare Community Plan are entitled to Covered Services for the period to which
the Premium applies.
8.3 Copayments. Copayments are not currently due for any Covered Services.
8.4 Claims. It is UnitedHealthcare Community Plan policy to pay providers directly for services.
If a Provider bills a Member for a Covered Service, the Member should send the bill to
UnitedHealthcare Community Plan. UnitedHealthcare Community Plan will not reimburse
Members for bills received by UnitedHealthcare Community Plan more than six (6) months
from the date of service. If the Member pays the bill, the Member must submit a request
for reimbursement in writing to UnitedHealthcare Community Plan immediately after paying
the bill.
8.4.1 When a Member gets services authorized by UnitedHealthcare Community Plan from a
Non-Participating Provider, the Member should ask the provider to bill UnitedHealthcare
Community Plan. If the provider bills the Member, the Member should send the bills to
UnitedHealthcare Community Plan. Bills must be sent within twelve (12) months of the
date of the service. If the provider requires the Member to pay at the time of the service,
the Member must ask UnitedHealthcare Community Plan for reimbursement right after
the service in writing.
8.4.2 The Member must send proof of payment with all requests for reimbursement. The proof
must be sent within 12 month time frame. Neither UnitedHealthcare Community Plan nor
the Member must pay more than Customary Charges.
8.4.3 UnitedHealthcare Community Plan may ask a Member to provide more information
before payment.
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Medicaid Certificate of Coverage (COC)
Article IX: Covered services
9.1 Member eligibility.
A Member is entitled to the services, equipment and supplies specified in Section 9.2
when they are:
A. Medically Necessary;
B. Performed, prescribed or or arranged by the Member’s PCP or another provider;
C. Authorized in advance by UnitedHealthcare Community Plan, if needed; and
D. Consistent with the Medicaid Agreement.
9.2 Covered services.
These are Covered Services when they meet the above requirements:
A. Primary Care Provider (PCP) office visits.
Each Member must pick a Primary Care Provider. This PCP is responsible for the
Member’s health care needs. This includes arranging referrals and hospital stays.
B. Specialist office visits, with referral from the PCP.
PCP will normally make referrals only to Participating Providers. The PCP may refer
to Non-Participating Providers when it is Medically Necessary to do so and the service
cannot be given by a Participating Provider. A referral to a Non-Participating Provider
must be approved in advance by UnitedHealthcare Community Plan. Specialist may
make further referrals. This requires the prior approval of the PCP and UnitedHealthcare
Community Plan.
C. Covered Services without a Referral from a PCP.
D. Preventive Health Services.
Preventive services from a PCP or other provider. These include services to prevent
illness, disease, disability and promote physical and behavioral health. Covered
Services by UnitedHealthcare Community Plan include:
1. Health assessments and exam recommended for the age and sex of the Member.
2. Prenatal and postpartum care.
3. Pediatric exams and well-child care.
4. Adult immunizations, except for travel or employment purposes.
5. Well-child visits and immunizations as covered by the EPSDT program.
6. Vision and hearing screenings. This does not include eye refraction testing.
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Medicaid Certificate of Coverage (COC)
7. Routine gynecological examinations.
8. Educational programs as described in the Member Handbook.
9. Breast cancer screening mammography.
a. One mammography exam for women 35–40 years of age.
b. One mammography exam every calendar year for women 40 years of age
or older.
c. Screenings ordered by a doctor.
d. “Breast cancer mammography” means a standard 2-view breast, low-dose
radiographic exam.
e. Hospital, medical or surgical expenses incurred for Prosthetic devices after a
mastectomy are covered benefits. They must be approved in advance. The cost
and fitting of a prosthetic device following a mastectomy is included within the
type of coverage intended by this section.
E. Family Planning Services are covered. This includes contraception counseling and
related exams. The following are covered services:
a. Voluntary Sterilizations. Tubal ligations and vasectomies are covered for
Members over the age of 21. Vasectomies are only covered when done in a
doctor’s office. A consent form must be sent to the plan 30 days in advance.
Reversals of sterilization are excluded.
b. Diaphragms and Intrauterine Devices (IUDs).
c. Advice on Contraception and Family Planning.
d. Abortion. Abortion is covered in the case of rape, incest or to save the life
of the mother.
e. Infertility diagnosis and testing is covered when medically necessary. Any
treatment for infertility is not a covered benefit.
F. Inpatient Hospital Services.
1. All inpatient Hospital Services, except for Emergency Services, must be at a
Participating Hospital. They must be set up by the PCP. They must be approved
in advance by UnitedHealthcare Community Plan except as set forth in Article VI,
Section 6.4.
2. Covered inpatient Hospital Services include semi-private room and board, general
nursing care, intensive care and all other Medically Necessary services and
supplies. These include radiological services, laboratory and other diagnostic tests,
pharmaceuticals, anesthesia, oxygen, chemotherapy and radiation therapy, blood
products, obstetrical services and other services by Health Professionals.
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Medicaid Certificate of Coverage (COC)
G. Outpatient Services.
1. Outpatient services must be given or set up by a PCP. They must be approved in
advance by UnitedHealthcare Community Plan. They may be done in the outpatient
department of a Participating Hospital. Or they may be done at another Participating
Provider location except as set forth in Article VI, Section 6.4.
2. Covered outpatient services include dialysis, chemotherapy, outpatient surgery
and related anesthesia services, diagnostic laboratory, diagnostic and therapeutic
radiological services, short-term rehabilitative therapy, and other services by
Health Professionals.
H. Oral Surgery.
Dental services not done by dentists are covered with prior approval. This includes
prescription drugs, laboratory and radiology services, anesthesia and hospitalizations.
I. Rehabilitation and Physical Therapy Services.
Short-term rehabilitative therapy is covered. This is limited to physical therapy for
rehabilitation, occupational therapy, language, speech and hearing therapy. This must
have prior approval. “Short-term” is a condition which can improve in a limited period.
J. Transplant Services.
Tissue or organ transplants, if medically necessary. These must have prior approval. All
costs for surgery and care organ procurement, donor searching and typing, harvesting
of organs, and related donor medical costs. Cornea, kidney, and extra renal organ
transplants (heart, lung, heart-lung, liver, pancreas, bone marrow, and small bowel) are
covered if medically necessary. Drugs used in antineoplastic therapy are covered.
1. Transplants will not be covered if:
a. UnitedHealthcare Community Plan does not give approval prior to evaluation;
b. The transplant is done in a facility that is not approved by UnitedHealthcare
Community Plan;
c. The transplant is experimental;
d. If other insurance or benefit program is responsible for paying for the services; or
e. The donor has not first exhausted all possible insurance services before
UnitedHealthcare Community Plan is billed.
2. Once the transplant is approved, UnitedHealthcare Community Plan will tell PCP
which facilities are approved for that type of transplant.
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Medicaid Certificate of Coverage (COC)
K. Home Health Care.
Home health care will be given when a Member is confined to their home. Home health
care visits are covered when set up by the PCP. They must be approved in advance.
Home health care includes: home care nursing services, skilled nursing care, and home
health aides. Drug and biological solutions, surgical dressings and related medical
supplies, and equipment used during home health care visits will be covered when
essential to proper care and prescribed by the PCP.
L. Skilled Nursing Facility and Hospice Services.
1. Skilled Nursing Facility.
Care and treatment, including room and board, in a semi-private room at a Skilled
Nursing Facility for up to forty-five (45) days per twelve (12) month period. This
must be set up by a PCP. It must be approved in advance by UnitedHealthcare
Community Plan. Skilled nursing facility services (non-Hospice care) must lead to
increased ability to function. It must be of a temporary nature. It must be supported
by a treatment plan. It must be approved in advance by UnitedHealthcare
Community Plan.
2. Hospice Services.
Hospice services for Members who have a prognosis of less than six (6) months to
live are covered. These may be in a variety of settings. They are given by a team who
attend to physical, emotional, and spiritual needs. A Referral must be made by the
PCP. UnitedHealthcare Community Plan must approve services in advance.
Hospice services are not based on medical need. It is an option for Members
diagnosed as having less than six (6) months to live.
Skilled Nursing Facility and Hospice Services in connection with custodial care,
domiciliary care, drug addiction, chronic organic brain syndrome, alcoholism,
intellectually disabled, senility or any behavioral health disorder are not covered.
Hospice Services for funerals and financial or legal counseling are not covered.
This includes planning estates or wills.
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Medicaid Certificate of Coverage (COC)
M. Prescription Drugs.
Drugs from the most current UnitedHealthcare Community Plan drug formulary are
covered. They must be ordered by a Participating Provider. They must be obtained
from a Participating Pharmacy. Insulin, needles and syringes used for injectable insulin
are covered. They must be ordered by a Participating Provider. They must be obtained
at a Participating Pharmacy. Prescriptions are limited to a thirty (30) day supply. Prior
authorization is required for off-label use of an US FDA approved drug and the
reasonable cost of supplies medically necessary to administer the drug. “Off-label”
means the use of a drug for clinical indications other than those stated in the labeling
approved by the US FDA.
Coverage is provided for antineoplastic therapy drugs if:
1. The drug is ordered by a doctor for the treatment of a specific type or neoplasm.
2. The drug is approved by the Food and Drug Administration for use in antineoplastic
therapy.
3. The drug is used as part of an antineoplastic drug regimen.
4. Current medical literature and oncology boards accept the treatment.
5. The patient has given informed consent.
N. Durable Medical Equipment, Prosthetics and Orthotics.
Special services such as durable medical equipment, prosthetics and orthotics, and
other medical supplies are covered when ordered by the PCP. They must be approved
in advance by UnitedHealthcare Community Plan. They must be provided by a
Participating Durable Medical Equipment Provider. UnitedHealthcare Community Plan
may require use of the least costly device.
O. Emergency Services.
Hospital care and other services for an emergency are covered.
Members should call their PCP before going to the emergency room. If a true
emergency, a delay might result in death or permanent impairment. In event of a true
emergency, Members should seek help from the nearest emergency facility right away.
They do not need to call their PCP first. Members should tell the emergency personnel
the name of their PCP. They should ask that he or she be contacted as soon as possible.
P. Ambulance Services.
Ambulance services in the case of an emergency. Non-emergent ambulance services
are covered if medically necessary and approved in advance by UnitedHealthcare
Community Plan.
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Medicaid Certificate of Coverage (COC)
Q. Vision Services.
Routine eye exams by Participating Providers are covered. A Referral is not needed
for a Participating Optometrist. Eye exams, prescription lenses and frames are covered.
All members may have one eye exam and one pair of glasses every twenty-four
months. Members under 21 may get two pairs of replacements for lost, broken or
stolen glasses every twelve months. Members age 21 or older may get one pair of
replacement glasses.
1. The Member may apply the cost allowed by UnitedHealthcare Community Plan for
eyeglass frames towards the cost of any pair of frames. The Member must pay any
difference between the cost allowed and the cost charged.
2. Sunglasses are not covered.
3. Contact lenses are covered only if the Member’s vision cannot be corrected with
glasses. Contact lenses require advance approval.
R. Hearing Examinations and Hearing Aids.
Hearing exams are covered if done or approved by the PCP. UnitedHealthcare
Community Plan will cover one single hearing aid unit per ear. They must be from a
licensed hearing aid dealer. This includes hearing aids and delivery. The hearing aid unit
must be FDA approved. Hearing aid repairs and adjustments; replacement earmolds;
and hearing aid supplies, accessories and batteries are covered.
S. Pregnancy Care.
Prenatal and postpartum care are covered by any OBGYN provider.
Maternal Infant Health Program (MIHP) is a home visiting program for women and
infants to promote healthy pregnancies, positive birth outcomes, and healthy infant
growth and development. MIHP covered services include:
• Prenatal teaching
• Childbirth education classes
• Nutritional support, education and counseling
• Breastfeeding or formula feeding support
• Help with personal problems that may complicate your pregnancy
• Newborn baby assessments
• Referrals to community resources and help finding baby cribs, car seats, clothing, etc.
• Support to stop smoking
• Help with substance abuse
• Personal care or home health services
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Medicaid Certificate of Coverage (COC)
Doula Services.
Doula support during the perinatal period is covered and may include, but is not
limited to:
• Prenatal services
• Labor and delivery services
• Postpartum services
T. Bariatric Surgery.
Bariatric surgery is covered only when medically needed. It must be approved in
advance by UnitedHealthcare Community Plan. The request must meet the Michigan
Association of Health Plans Bariatric Surgery Guidelines.
U. Diabetes Treatment Services.
The equipment, supplies, and educational training for diabetes listed below are covered.
They must be prescribed by a Participating Provider:
1. Blood glucose monitors and blood glucose monitors for the legally blind.
2. Test strips for glucose monitors, visual reading and urine testing strips, lancets,
and spring-powered lancet devices.
3. Syringes.
4. Insulin pumps and medical supplies needed for the use of an insulin pump.
5. Diabetes self-management training.
The following medications for diabetes are covered. They must be ordered by a
Participating Provider.
• Insulin
• Non-experimental medication for controlling blood sugar
• Medications used for foot ailments, infections, and other medical conditions
of the foot, ankle, or nails related to diabetes
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Medicaid Certificate of Coverage (COC)
V. Behavioral Health Services.
Behavioral Health Visits are unlimited. UnitedHealthcare members can see a
Participating Provider without a referral from a PCP. Behavioral Health information is
provided by Optum Behavioral Health Services at 1-800-903-5253. For long term mental
health treatment UnitedHealthcare will work with Community Mental Health to get
member the needed care.
W. Dental Services.
Dental services for adults age 21 and older are covered. Services include diagnostic,
preventative, minor restorative and oral surgery.
X. Telemedicine.
Telemedicine services are covered and must be provided by a health care professional
who is licensed, registered, or otherwise authorized to engage in his health care
profession in the state where the patient is located.
Article X: Emergency or urgent care in the service area
10.1 Emergency Services. A Member should go to a Hospital emergency room for emergency
care. The Member’s PCP must be notified within twenty-four (24) hours after treatment.
If the member is hospitalized, the PCP should be notified as soon as possible.
10.2 Urgent Care. A Member must call his or her PCP before getting Urgent Care. The Member
must contact the PCP for all follow-up care.
Article XI: Out-of-area services
11.1 Covered Services. Emergency Services are covered by UnitedHealthcare Community
Plan if the Member is only temporarily out of the Service Area. Routine medical care
outside of the Service Area is covered with prior authorization from UnitedHealthcare
Community Plan.
11.2 Hospitalization. If an Emergency visit requires hospitalization, the Member’s PCP must
be contacted within twenty-four (24) hours. The PCP may require the Member to move
to a Participating Hospital when possible.
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Medicaid Certificate of Coverage (COC)
Article XII: Exclusions and limitations
12.1 Exclusions. These services, equipment and supplies are Non-Covered Services:
A. Any service, equipment or supply not listed in Section 9.2.
B. Personal or comfort items.
C. Services, equipment or supplies not directed by the PCP or provider or not approved
in advance by UnitedHealthcare Community Plan.
D. Sports-related physicals, surgery, related services and durable medical equipment.
E. Services, equipment and supplies which are not Medically Necessary.
F. Routine dental services, except as in Section 9.2.
G. Medical exams to confirm health status for third parties. This includes for employment,
insurance, or for a court.
H. Surgery and care to improve appearance, unless needed medically.
I. Items for cleanliness and grooming.
J. Substance abuse services. Refer to UnitedHealthcare Community Plan Member
Handbook for a list of outreach services.
K. Experimental medical, surgical or other health care drug, device or treatment. This is
determined by the Medical Director and the Department.
L. Reproductive Services. Reversal of elective sterilization is excluded. Reversal of elective
sterilization is excluded. In-Vitro fertilization, GIFT, artificial insemination, ZIFT,
intrauterine insemination (IUI), and any infertility treatments are excluded.
M. Any service, equipment or supply usually given free of charge.
N. Abortions, except to save the life of the mother or for incest or rape.
O. Inpatient services in a Long-Term Care Facility. This does not include rehabilitation care
for up to 45 days.
P. Acupuncture.
Q. Services from a school-based provider per the Medicaid Agreement.
R. Services by a community health board per the Medicaid Agreement.
S. Care from a Veterans, Marine or other federal hospital. Or care that by law must be
treated in a public facility.
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Medicaid Certificate of Coverage (COC)
T. Inpatient services in facilities for the developmentally or intellectually disabled or care
in a psychiatric hospital.
U. Over-the-counter medications if not prescribed.
V. Non-Emergency Services from a Non-Participating Provider or unless approved in
advance by UnitedHealthcare Community Plan.
W. Personal care services in a Member’s home.
X. Private duty nursing services covered by other Medicaid programs.
Y. Durable Medical Equipment benefits do not include:
1. Deluxe equipment that is not Medically Necessary.
2. Environmental control equipment including, but not limited to, air conditioners.
3. Bathing or hygienic equipment including, but not limited to, swimming pools and
hot tubs.
4. Hypo-needle injectors.
5. Seat cushions.
6. Support garments (including cervical collars).
7. Comfort or convenience items.
8. Exercise equipment, including, but not limited to, weight training.
9. Back-up generators.
10. Dental prostheses.
11. Dental braces and appliances.
12. Medications paid through the Department of Community Health
Fee-For-Service program.
12.2 Limitations.
12.2.1 Covered Services are subject to the limits described in the UnitedHealthcare Community
Plan Medicaid Agreement, the Medicaid Program Provider Manuals and Medicaid bulletins
and directives.
12.2.2 UnitedHealthcare Community Plan has no liability or obligation for any services from a
Non-Participating Provider unless these are approved in advance by UnitedHealthcare
Community Plan. This does not include emergency care.
12.2.3 A Referral by a PCP for Non-Covered Services does not mean they are covered.
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Medicaid Certificate of Coverage (COC)
Article XIII: Term and termination
13.1 Term . This Certificate takes effect on the date stated in the Medicaid Agreement. It stays
in effect from year to year unless stated in the Medicaid Agreement or terminated.
13.2 Termination of Certificate by UnitedHealthcare Community Plan or the Department.
13. 2.1 This Certificate will terminate on the date of termination of the Medicaid Agreement.
Coverage will terminate at 12:00 Midnight on the date of the termination of this Certificate,
unless stated in the Medicaid Agreement.
13.2.2 In the event of cessation of operations by UnitedHealthcare Community Plan, this
Certificate may be terminated immediately. UnitedHealthcare Community Plan will be
obligated for services for period for which premiums were paid or as prescribed by law
or by the Medicaid Agreement.
13.2.3 UnitedHealthcare Community will notify members of the termination of this Certificate.
The fact that Members are not notified will not extend Members’ coverage.
13.3 Termination of Enrollment and Coverage by UnitedHealthcare Community Plan or
the Department.
13.3.1 A Member’s enrollment and coverage will terminate per the Medicaid Agreement when:
A. The Member moves out of the Service Area.
B. The Member ceases to be eligible for the Medicaid Program.
C. The Member dies.
D. The Member is given active eligibility status as a child with special health care needs.
E. The Member is admitted to a Long-Term Care Facility. This does not include rehab care
(45 days) or Hospice.
F. The Member is admitted to a state psychiatric hospital.
13.3.2 UnitedHealthcare Community Plan may disenroll a Member for cause. This includes:
A. The Member cannot keep a relationship with a PCP after two tries;
B. The Member misrepresents or commits fraud in applying for enrollment; or
C. The Member misuses or commits fraud in the use of his or her UnitedHealthcare
Community Plan ID card; or
D. The Member’s conduct is abusive or obstructive to UnitedHealthcare Community Plan
personnel, Participating Providers or other Members; or
E. The Member repeatedly misuses UnitedHealthcare Community Plan benefits and
services; or
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Medicaid Certificate of Coverage (COC)
F. The Member fails to cooperate in coordinating benefits or subrogating the Member’s
right of recovery.
13.3.3 UnitedHealthcare Community Plan will not terminate a Member’s enrollment on the basis
of health or health care needs. A Member will not be terminated for using the Complaint,
Grievance and Appeal process.
13.4 Disenrollment by Member.
13.4.1 A Member may disenroll from UnitedHealthcare Community Plan with or without cause.
To do so, a Member should contact the UnitedHealthcare Community Plan Customer
Service Department. The Member must follow disenrollment.
13.4.2 A Member’s coverage stops on the date of the Member’s disenrollment. The date of
disenrollment will be determined by the Department.
Article XIV: Coordination of benefits
14.1 Purp ose. UnitedHealthcare Community Plan will coordinate benefits for a Member with
benefits from health insurance carriers and other health benefit plans who also provide
coverage for the Member. A Member, or their agent, must inform UnitedHealthcare
Community Plan of all health insurance carriers and other health benefit plans for the
Member. Each Member, or agent, must certify that the health insurance carriers and
other health benefit plans listed in his or her application are the only ones from whom the
Member has any rights to payment of health care. Each Member, or agent, must also
notify UnitedHealthcare Community Plan when any other health insurance carrier and
other health benefit plan becomes available to the Member. The Member agrees that any
misrepresentation may result in disenrollment.
14.2 Assignment.
14.2 .1 Upon UnitedHealthcare Community Plan request, a Member must assign to
UnitedHealthcare Community Plan:
A. All insurance and other health care benefits, and other private or governmental benefits
(except Medicaid) for health care of the Member; and
B. All rights to payment and all money paid for any claims for health care received by
the Member.
14.2.2 Members shall not assign benefits or payments for Covered Services to any other person
or entity.
14.3 Claims. Upon UnitedHealthcare Community Plan request, a Member must authorize
UnitedHealthcare Community Plan to submit claims for the Member to Medicare and other
health insurance carriers and other health benefit plans.
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Medicaid Certificate of Coverage (COC)
14.4 Order of Benefits. UnitedHealthcare Community Plan will follow Medicaid coordination
of benefits guidelines and laws.
14.5 UnitedHealthcare Community Plan Rights. UnitedHealthcare Community Plan is
entitled to:
A. Determine to what extent a Member has health benefit coverage; and
B. Determine responsibility among the health insurance carriers and other health benefit
plans; and
C. Require a Member or provider to file a claim with the primary health insurance carrier
or other health benefits plan; and
D. Recover costs from the Member or provider for services covered by any other health
insurance carriers and other health benefit plans; and
E. Recover costs from the Member or provider for Non-Covered Services that were
provided due to the Member’s error.
14.6 Construction. UnitedHealthcare Community Plan does not have to make payment until
it determines what benefits are payable by the primary health insurance carrier and other
health benefit plan.
Article XV: Subrogation
15.1 Assignment; Suit. If a Member has a right of recovery for an injury or illness, other than a
health plan, the Member must:
A. Pay or assign to UnitedHealthcare Community Plan all sums recovered up to the amount
of UnitedHealthcare Community care expenses; or
B. Authorize UnitedHealthcare Community Plan to get all medical records relating to the
injury or illness.
C. Authorize UnitedHealthcare Community Plan to be subrogated to the Member’s rights
of recovery up to the amount of UnitedHealthcare Community care expenses for the
injury or illness. UnitedHealthcare Community Plan also has the right to recover suit and
attorney fees.
15.2 Definition. Health care expense means the amounts paid or to be paid by UnitedHealthcare
Community Plan to providers for services given to a Member.
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Medicaid Certificate of Coverage (COC)
Article XVI: Miscellaneous
16.1 Governing Law. This Certificate is made and shall be interpreted under the laws of the
State of Michigan.
16.2 Contract. This Certificate shall be construed as a Contract under the laws of the State
of Michigan.
16.3 Period of Time for Legal Claims. Any dispute regarding this Certificate shall be
made within a reasonable time. The time period should be no later than three years from
the dispute.
16.4 Policies and Procedures. UnitedHealthcare Community Plan may adopt policies,
procedures and rules to administer this Certificate, the Member Agreement, and the
Medicaid Agreement.
16.5 Notice.
16.5.1 Any notice required from UnitedHealthcare Community Plan to a Member shall be in
writing. It will be delivered or deposited in the U.S. Mail. It will be sent to the Member’s
address on file with UnitedHealthcare Community Plan.
16.5.2 Any notice required by the Member to UnitedHealthcare Community Plan shall be in writing.
It should be sent to:
UnitedHealthcare Community Plan, Inc.
3000 Town Center, Suite 1400
Southfield, Ml 48075
16.6 Headings. The headings are not part of this Certificate.
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