UnitedHealthcare Community Plan KanCare

Our plan has a range of benefits and extras that other KanCare plans don't offer. We provide extra support and care to adults and children who need help with daily activities. You qualify based on income and health needs. Click View Plan Details to learn more.

This plan is available in the following counties:

Allen , Anderson , Atchison , Barber , Barton , Bourbon , Brown , Butler , Chase , Chautauqua , Cherokee , Cheyenne , Clark , Clay , Cloud , Coffey , Comanche , Cowley , Crawford , Decatur , Dickinson , Doniphan , Douglas , Edwards , Elk , Ellis , Ellsworth , Finney , Ford , Franklin , Geary , Gove , Graham , Grant , Gray , Greeley , Greenwood , Hamilton , Harper , Harvey , Haskell , Hodgeman , Jackson , Jefferson , Jewell , Johnson , Kearny , Kingman , Kiowa , Labette , Lane , Leavenworth , Lincoln , Linn , Logan , Lyon , Marion , Marshall , McPherson , Meade , Miami , Mitchell , Montgomery , Morris , Morton , Nemaha , Neosho , Ness , Norton , Osage , Osborne , Ottawa , Pawnee , Phillips , Pottawatomie , Pratt , Rawlins , Reno , Republic , Rice , Riley , Rooks , Rush , Russell , Saline , Scott , Sedgwick , Seward , Shawnee , Sheridan , Sherman , Smith , Stafford , Stanton , Stevens , Sumner , Thomas , Trego , Wabaunsee , Wallace , Washington , Wichita , Wilson , Woodson , and Wyandotte .

More information on eligibility and enrollment can be found on the KanCare website.

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Benefits & features

Well and Sick Care

Get the care needed to stay healthy — or to be at your best. That includes:

• Choice of Doctors. Find a doctor you know and trust in our network.
• Medicines. Fill your prescriptions at local pharmacies.
• Lab and X-rays. Lab tests, x-rays and diagnostic imaging are covered.
• Therapy Services. Physical or other therapy to help be your best.
• Shots and Vaccines. Routine shots help protect against illness.
• Hospitalization. You pay nothing for care in a hospital.
• Nurse Hotline. Speak with a registered nurse 24/7.
• Foot Care. We provide more visits to keep your feet healthy.
• Community Rewards. You can earn rewards for going to important wellness exams.

Pregnancy Care

Nothing is more important than the health and well-being of you and your baby. That's why our plan benefits include:

• Choice of Birth Center. You can choose a licensed community birth center or pick from 100s of hospitals across Kansas.
• Choice of Doctors. Find a certified nurse midwife, licensed midwife, doctor or OB/GYN you trust in our network.
• Healthy First Steps®. Get extra support and rewards to keep you and your baby healthy.
• Prenatal Visits. Care for you before your baby is born. Earn reward for completing first prenatal visit in the first trimester.

Care for Conditions

If you or a family member has special health care needs, you can count on us. Our plan will provide the needed extra care and services. Benefits include:

• Behavioral Health. Counseling and other treatments are covered.
• Diabetic Support. Medicine needles and wipes for managing diabetes.
• Asthma and COPD Support. Exams, testing and supplies are covered.
• Care Management. If you qualify, get personal help managing health conditions.
• Kidney Disease Care. Dialysis, medicine and treatments are covered.
• Health Rewards Program. Earn debit card rewards for well care visits and immunizations.

Vision, Dental and Hearing Care

Make sure your sight, smile and hearing are at their best. Benefits include:

• Vision Care. Yearly eye exams and eyeglasses as needed.
• Dental Care. Exams, x-rays and cleaning for kids and adults.
• Hearing Care. Tests, checkups and hearing aids, if needed.

Home Care and Supplies

If you are recovering from a serious illness or surgery, you may need extra support. Our plan includes the care and equipment needed to recover safely at home. Benefits include:

• Equipment and Supplies. In-home medical and safety equipment are covered.

Rides and Other Help

Sometimes you might need a little extra help using your health plan. For those times, you can rely on:

• Transportation. We provide rides to and from medical visits.
• Community Rewards. Your can earn rewards for going to important wellness exams.
• Programs for Kids and Teens. Free activities at local youth organizations.
• Member Services. Your benefit questions are answered Monday – Friday 8 am – 6 pm 1-877-542-9238.
• Quitting Tobacco. Coaches and supplies to help you quit using tobacco.
• Interpreters. Interpreters are available over the phone for you at your doctor visits.

Home and Community Services

If you're elderly or living with a disability or illness, your health needs are unique. Our job is to make it as easy as possible for you to meet those needs and more. Benefits may include:

• Care Coordinator. Someone to get you the services to be at your best.
• Disease Management. Focused care for those with critical health needs.
• In-Home Care. Medical and personal care at home, if needed.
• Equipment and Supplies. In-home medical and safety equipment are covered.
• Emergency Response System. Sends an urgent request for someone to help you.
• Adult Day Care. Friendship and social activities in a safe setting.
• Home Meal Delivery. If you cannot safely make meals, we'll provide them.
• Respite Care. In-home help to give your caregivers a rest.

Value-added benefits

Below are a few additional benefits and services KanCare offers. Our full list can be found here. English | Español

• Adult dental: Members 21 and over are eligible for additional dental benefits like specialty x-rays and specialty preventive treatments up to $500 per year. For help, call member services 1-877-542-9238, TTY 711
• Additional vision: Adult members over 21 can get an additional $60 to upgrade their frames, once a year. Ask your Vision provider. Providers wanting to participate can work with UnitedHealthcare Provider Services.
• Healthy rewards: Earn a Rewards debit card* for completing things like annual health assessment and well-child annual visits. Reward amounts are $10 and $25 (up to $75 annually). Once a member completes an activity, a card will be mailed, or reward will be added to existing card.

Adult Day Care

Companionship is important. Adult day care provides care and companionship for frail elderly waiver members who need extra help during the day. Caregivers also benefit, knowing their loved one is well cared for and safe during the day.

Adult day care can provide:

• Social connections and friendship.
• Bathing and personal care.
• Meals.

Asthma and COPD Support

Do you or a family member have trouble managing asthma or COPD symptoms? A nurse who specializes in breathing issues can really help. You will get a customized treatment plan and medicine to:

• Manage flare-ups.
• Reduce symptoms.
• Help you stay active.

Attendant Care Services

If you live with a disability or chronic health condition, you may need extra help to stay in your own home. Our plan gives members who qualify the services needed to be safe and comfortable. An attendant can provide:

• Companionship.
• Homemaking services.
• Personal care.

You and your caregiver can decide which chores you want your care attendant to do in your home.

Behavioral Health

Behavioral health is as important as physical health. That's why we have coverage for both.

Required care is 100% covered with no copay. This includes:

• Behavioral therapy.
• Substance abuse treatment.
• Medications.
• Peer Coaching program.

Care Coordinator

The daily care and safety of our members is important. That’s why we conduct home visits for eligible waiver members who need extra help staying at home.

During this visit we:

• Understand your personal needs.
• See if your home needs minor modifications, such as ramps and bathroom safety devices.
• Set up emergency monitoring.
• Arrange for personal care attendants.

Care Management

Do you have a disability or a serious health problem? If your health needs qualify then our care coordinators are in your corner. They will:

• Explain medical terms in plain language.
• Coordinate your doctor appointments.
• Provide your care team with your medical records.

Your care coordinator will stay with you throughout the medical journey. He or she will:

• Think beyond your immediate medical needs.
• Make sure you have support at home.

Choice of Birth Center

Where you have your baby is an important choice. That's why you can pick from hospitals across Kansas and surrounding states.

We also encourage you to tour the hospital's birthing center. This way you will be familiar with it. And be more relaxed when you have your baby.

Cell Phone Program

Contact Member Services for help applying for a cell phone plan.

Choice of Doctors

You get a primary care physician (PCP) who is your main doctor. Use the Doctor Lookup tool to see if your doctor is in our network.

If you don't have a doctor or if your doctor is not in our network, we can help you find a new one close to you.

Your PCP is your main doctor for:

• Preventive care.
• Treatment if you are sick or injured.
• Referrals to specialists for certain conditions.

Dental Care

Child members up to age 20 receive Preventative exams and cleaning 2 times a year. This helps keep teeth and gums strong and healthy.

Adults over 20 can visit participating dental provider for exams, x-rays, cleanings and fillings. Covers up to $500 per year*.

*The $500 coverage that includes fillings begins in 2019

Diabetic Support

If you have diabetes, we'll help make life a little easier for you. You'll get medicine, supplies and education to help you reach and stay your best.

Our diabetes program also includes self-care training and classes focused on:

• Planning healthy meals.
• Managing stress.
• Living a healthy lifestyle.
• Wellness Rewards for getting needed exams.

Disease Management

If you have chronic or high-risk illnesses, our disease management services may help you. We provide support for:

• Congestive heart failure.
• Asthma.
• HIV.
• Chronic obstructive pulmonary disease (COPD).
• Coronary artery disease.

Emergency Response System

If you are on one of the waiver programs and at risk for a fall or sudden illness, an emergency call system can really help. It sends an urgent request for someone to check on you and help you.

Equipment and Medical Supplies

Your health and safety at home are important.

Our plan covers medical equipment ordered by your doctor. This might include supplies like:

• Oxygen tanks.
• Hospital beds.
• Wheelchairs or walkers.

Foot Care

Children can get the exams needed to help keep your feet in great shape. And if you have diabetes, good foot care can help prevent much more serious problems.

Our podiatry coverage includes:

• Routine foot exams.
• Tips about foot care and choosing the right shoes.
• Information about nerve damage warning signs.

Healthy First Steps®

Build a healthy future for you and your baby and earn great rewards with Healthy First Steps. Our program will help you take the right steps to keep you and your baby healthy. Plus you can earn $20 just for signing up.

We will help you:

• Choose a pregnancy provider and a pediatrician (child’s doctor).
• Schedule visits and exams and arrange rides to your visits.
• Earn rewards for going to visits throughout your pregnancy and baby’s first 15 months of life.
• Get supplies, including breast pumps for nursing moms.
• Connect with community resources such as Women, Infants and Children (WIC) services.

Hearing Care

Trouble hearing can affect your everyday life in many ways. Our plan includes services and support to help protect your hearing.

• Exams, therapy and tests.
• Hearing aids when ordered by your doctor.

Home Meal Delivery

If you are on the PD or TBI waiver and live with a disability or chronic health condition, we may be able to arrange home meal deliver. You will not be eligible if you are getting home meals through different program.

Hospitalization

This plan pays for all expenses related to a hospital stay, so you can rest and heal.

Hospitalization coverage includes:

• Nursing care.
• Room and board.
• Supplies and equipment.
• Treatment and therapies.
• Diagnostic tests and exams.

And after you leave the hospital, you are not alone. We make sure you get follow-up care to continue healing at home.

In-Home Care / Skilled Home Health Care Services

If you have health or mobility challenges, you may need extra help with day-to-day tasks. You may even need an in-home medical visit to check on how well you are healing. If ordered by a doctor for medical reasons, our Plan covers:

• In-home medical visits.
• Medical equipment like hospital beds, walkers or wheelchairs.
• Disposable medical supplies.
• Help with personal care or housekeeping.

Interpreters

Your doctor and you need to understand each other. Not speaking English well makes this difficult. We can arrange for a medical interpreter to be available for you over the telephone at your appointments.

We also have people in member services who speak more than one language. Chances are, we have someone who speaks your language.

Kidney Disease Care

Kidney disease is a serious medical condition. After the kidneys stop working, regular treatments (called renal dialysis) or an organ transplant are necessary. Dialysis uses a machine to clean the blood, just like healthy kidneys do. Our plan includes:

• Dialysis.
• Medications.
• Health education and support.
• Organ transplant if needed.

Lab and X-rays

Knowing what's wrong and finding it early can make all the difference. Our plan covers:

• Labs and testing.
• X-rays, scans and other imaging.

We'll help you get the information needed to improve your health or be at your best.

Medicines

There are no copays for covered drugs. You can fill your prescriptions at local pharmacies.

The medical card will cover many services and items. In order for a service to be covered, you must use a Kansas Medicaid provider. The type of coverage you have will determine how you receive coverage.

Specific limits and guidelines apply to all services, and these change often. Before getting any service or item, contact KMAP/MCO Customer Service. A general list of KMAP/MCO covered services is included on our website at https://www.kmap-state-ks.us/Public/Beneficiary/default.asp.

Medicaid requires some services to be approved before you get them. Your provider knows which services need prior authorization and is responsible for obtaining it for you. Medicaid will send you and your provider a letter approving or denying the prior authorization request.

Member Advocates

We're looking out for you. Member advocates can help solve problems, provide training and education, and work on issues that concern members.

• Provide information about your plan.
• Teach you how to get the care you need.
• Help with doctor issues or complaints.
• Call Member Services and ask for a Member Advocate to help you.

Member Services

Sometimes you might need a little help understanding your health care options. With us, you have someone you can call Monday-Friday 8 am - 6 pm at 1-877-542-9238. We'll answer your questions simply and completely.

We can also help you find:

• Doctors.
• Pharmacies.
• Hospitals or other health facilities.
• Local resources.

NurseLine

Medical questions and situations sometimes happen at inconvenient times. When you have questions about your health, you can call a nurse 24 hours a day, 7 days a week. Call 1-855-575-0136.

Our nurses will:

• Listen to symptoms.
• Help with self-care.
• Advise you about getting care at a doctor visit or an urgent care center.
• Help you know when to go to the emergency room.

Prenatal Visits

Your pregnancy is a journey and you will need help along the way. You can visit a family doctor or pregnancy doctor (OB-GYN) to get the care you need.

All recommended prenatal clinical visits and tests are covered by our plan.

At these visits, the clinic will:

• Make sure both you and your baby are healthy.
• Explain what to expect at each stage of your pregnancy.
• Answer your questions.

Programs for Kids and Teens

Positive role models can make a big difference in a child's life. That's why we provide one free activity each year at local youth organizations, like:

• YMCA.
• Boys & Girls Clubs.
• 4-H.
• Select Kansas Park and Recreation Departments.

Quitting tobacco

Trying to stop smoking is hard. But all the benefits of quitting are worth it. Did you know that 20 minutes after you quit, your heart rate drops to a normal level? And 12-24 hours after quitting, the carbon monoxide level in your blood drops to normal. We support our members who are trying to quit.

• Visit your doctor to get advice and medicines that can help you quit. We can help you schedule an appointment.
• Medicines come in different forms like patches, gum, lozenges and pills. Most of these are covered by your benefits. We can also help you understand your other benefits too.
• Reach out to the KanQuit smoking line at 1-800-784-8669 for support 24/7 or go to: http://www.kssmokefree.org/quitting_help.html for more information.

Respite Care

Are you a waiver member who has family members or friends who care for you in your home? If so, we want to support their hard work too. That's why we provide respite care to give your caregivers a rest. Respite care offers caregivers time away from their loved one who is ill or has special care needs. Some members can get extra respite care. Ask your Care Coordinator if you qualify.

Shots and Vaccines

Routine shots help protect you from illness. So, our plan covers:

• Pneumonia, influenza and shingles shots.
• Tetanus, diphtheria, pertussis.
• HPV.

Therapy Services

Physical, occupational and speech therapy can help you recover from a serious injury or illness, or simply reach your full potential.

When approved by a doctor, covered therapies include:

• Occupational therapy.
• Physical therapy.
• Speech therapy.

Transportation

Our plan provides needed rides to and from health care locations for medical appointments. That includes trips to:

• Doctor or therapy visits.
• Health departments.
• Vision clinics.
• Rides to job activities for members who qualify.

Vision Care

You'll get the care, eyeglasses and treatment that let you see life more clearly. Coverage includes:

• Annual eye exams.
• Prescription lenses.

This benefit is offered by OptiCare.

Well Visits

Well visits with your doctor can help keep you healthy. These visits can catch health problems early, so they can be treated. Preventive services include:

• Checkups for adults and children.
• Routine shots and tests.
• Mammograms.

There are no copayments for preventive care. Earn Community Rewards points for getting exams.

Member resources

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Member resources

Kansas UnitedHealthcare Community Plan KanCare

We want to make it as easy as possible for you to get the most from your health plan. Our communications and materials below will help you learn more about benefits and available resources.

If you need a copy in large print or other format, or other language, please call 1-800-421-6204. The materials will be mailed to you within 5 business days, at no cost.

Member handbook

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Gas Reimbursement

Did you know you can get gas reimbursement for your non-emergency medical transportation? Click here to get the forms you need:

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How to Contact Us

If you have questions about your health plan, call us. Our toll-free Member Services number is 1-877-360-3240 (TTY: 711).

They can talk to you from Monday to Friday, 8:00 a.m. to 6:00 p.m., in English, Spanish or other languages.

We want to hear from you!

Member Advisory Board

Please join our Member Advisory Board. Contact member Services at 1-877-360-3240.

2024 Meeting Schedule

Q3: Wednesday, September 25th, 2024
Q4: Wednesday, December 18th, 2024

How We Support Cultural Competency

UnitedHealthcare Community Plan of Kansas seeks to understand the cultural differences of the people we serve. Our goal is to develop and improve our materials and programs to support the diverse needs of Kansans. Staff training focused on:

• Using your primary language.
• Being aware of the different cultural groups in Kansas.
• Ways to support cultural beliefs related to health and wellness.
• Treating each person with care and respect.
• To avoid labels.
• How to work with members with limited English.
• How to support those with special health care needs.
• Cultural sensitivity training.

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I/DD Members

This information is directed at the member. UnitedHealthcare Community Plan is also aware of the important role of the member’s support team. Family, guardians or representatives can be a big help in getting the right services, and can use this information to assist in supporting the member.

The Home and Community‐Based Services Intellectual/Developmental Disability (HCBS I/DD) program is designed to provide critical long term care support services, in the community setting of choice for beneficiaries that would otherwise require institutionalization in an intermediate care facility for an ICF‐ID (intermediate care facility for intellectual disabilities). The KanCare HCBS I/DD program is administered by the Kansas Department of Aging and Disability Services (KDADS).

Consistent with the Developmental Disabilities Reform Act of 1995 (DDRA), the goals and objectives of the program center around the policy of the State to provide persons who have intellectual and/or developmental disabilities access to services and supports which allow for these persons opportunities for choice that increase their independence, productivity, integration and inclusion in the community. Further, this range of supports and services will be appropriate to each person and will be provided in a manner that affords the same dignity and respect to per persons with intellectual or developmental disabilities that would be afforded to any person who does not have a disability.

HCBS I/DD goals conform to the Developmental Disabilities Reform Act of 1995 (DDRA). The policy is to provide access to services that allow persons to be more independent. It is to help people with disabilities be a part of the community. It is to help them be more productive. This help is tailored to each person. It is given with dignity and respect.

Kancare/UnitedHealthcare Community Plan is managing your HCBS I/DD services. You will be able to keep your same community providers, including your target case manager. There are 13 services under the I/DD program. You may be getting some or all of them.

• Assistive Services
• Day Supports
• Financial Management Service (FMS)
• Medical Alert
• Overnight Respite
• Personal Assistant Services
• Residential Supports
• Sleep Cycle Support
• Specialized Medical Care
• Supported Employment
• Supportive Home Care (SHC)
• Wellness Monitoring
• Targeted Case Management (TCM)

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Extra Coverage and Programs

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Intellectual/Developmental Disability (I/DD) Benefits Supplement

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2018

(Opens in new window) PDF 1.73MB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 1.71MB - Last Updated: 04/21/2023

(Opens in new window) PDF 1.74MB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 1.73MB - Last Updated: 04/21/2023

(Opens in new window) PDF 375.59KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 381.46KB - Last Updated: 04/21/2023

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(Se abre en una ventana nueva) PDF 417.00KB - Last Updated: 04/21/2023

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(Se abre en una ventana nueva) PDF 553.18KB - Last Updated: 04/21/2023

(Opens in new window) PDF 671.45KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 657.91KB - Last Updated: 04/21/2023

2017

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(Se abre en una ventana nueva) PDF 399.16KB - Last Updated: 04/21/2023

(Opens in new window) PDF 528.92KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 493.76KB - Last Updated: 04/21/2023

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(Se abre en una ventana nueva) PDF 342.36KB - Last Updated: 04/21/2023

(Opens in new window) PDF 416.94KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 373.46KB - Last Updated: 04/21/2023

(Opens in new window) PDF 412.80KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 394.48KB - Last Updated: 04/21/2023

(Opens in new window) PDF 455.10KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 473.29KB - Last Updated: 04/21/2023

(Opens in new window) PDF 578.29KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 548.12KB - Last Updated: 04/21/2023

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(Se abre en una ventana nueva) PDF 624.25KB - Last Updated: 04/21/2023

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(Se abre en una ventana nueva) PDF 705.89KB - Last Updated: 04/21/2023

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2016

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(Opens in new window) PDF 489.94KB - Last Updated: 04/21/2023

(Opens in new window) PDF 373.38KB - Last Updated: 04/21/2023

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(Se abre en una ventana nueva) PDF 488.11KB - Last Updated: 04/21/2023

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Member newsletters prior to 2016

2015

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(Se abre en una ventana nueva) PDF 412.08KB - Last Updated: 04/21/2023

(Opens in new window) PDF 1.86MB - Last Updated: 04/21/2023

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(Opens in new window) PDF 1.79MB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 336.76KB - Last Updated: 04/21/2023

(Opens in new window) PDF 697.08KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 688.98KB - Last Updated: 04/21/2023

(Opens in new window) PDF 442.22KB - Last Updated: 04/21/2023

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(Opens in new window) PDF 561.79KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 565.94KB - Last Updated: 04/21/2023

2014

(Opens in new window) PDF 2.29MB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 2.11MB - Last Updated: 04/21/2023

(Opens in new window) PDF 567.74KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 435.32KB - Last Updated: 04/21/2023

(Opens in new window) PDF 668.59KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 651.43KB - Last Updated: 04/21/2023

(Opens in new window) PDF 650.39KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 667.21KB - Last Updated: 04/21/2023

2013

(Opens in new window) PDF 709.36KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 671.86KB - Last Updated: 04/21/2023

(Opens in new window) PDF 953.08KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 1.06MB - Last Updated: 04/21/2023

(Opens in new window) PDF 1.61MB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 1.61MB - Last Updated: 04/21/2023

(Opens in new window) PDF 801.98KB - Last Updated: 04/21/2023

(Se abre en una ventana nueva) PDF 802.33KB - Last Updated: 04/21/2023

Advance Directive/Power of Attorney Forms

Information about Advance Directives

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Click here to go to a page provided by the State of Kansas for Advance Directive and Power of Attorney forms.

For more information on Advanced Directives, please visit kansaslegalservices.org.

Self direction for care attendants

Information on Self Direction

(Opens in new window) PDF 522.27KB - Last Updated: 04/21/2023

For more information about about Self-Direction, contact your Care Coordinator or go to the KDADS website.

Language Help

Click below for language help.

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Extra Coverage and Programs

We offer additional benefits to help you live a healthier life, such as expanded dental benefits for adults, extra transportation, get $50 towards a healthy activity at many local YMCA, Boys & Girls Club, Parks & Rec and more. View a full list of added benefits.

Authorized Representative Designation

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Practice Guidelines

UnitedHealthcare Community Plan has practice guidelines that help providers make healthcare decisions. These guidelines come from nationally recognized sources.

View the entire list of guidelines below or to request a printed copy call our Member Services toll-free at 1-877-542-9238 (TTY: 711).

Reviewed by UnitedHealthcare Community Plan Provider Advisory Committee on September 17, 2014.

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Fraud or Abuse

If you suspect provider fraud or abuse, call UnitedHealthcare Community Plan's hotline at 1-877-766-3844. You do not have to give your name, the provider will not be told you called.

Grievances, appeals and State Fair Hearings

Grievances, appeals and State Fair Hearings

If you have any questions about grievances, appeals or State Fair Hearings, call us toll-free at 1-877-542-9238, TTY 711. Interpreter services are also available free of charge.

What is a grievance?

A grievance is when you are unhappy about any matter other than an Adverse Benefit Determination. You may file a grievance if you do not agree with a decision made by UnitedHealthcare. If you are unhappy or concerned about the quality of care you received, you can file a grievance to be referred to our Medical Peer Review Committee. You may file a grievance at any time.

Here are some examples:

• You are unhappy or concerned with the quality of your care
• The doctor you want to see is not a UnitedHealthcare Community Plan doctor
• You cannot get culturally competent care
• You got a bill for a service that should be covered by UnitedHealthcare Community Plan
• Rights and dignity
• Any other issues about access to care

What should I do if I have a grievance?

You may file a grievance if you disagree with a decision made by UnitedHealthcare Community Plan. You or someone acting for you can file the grievance. You can request a grievance in the following ways:

Call Member Services toll-free:

1-877-542-9238, TTY 711

In writing:

Grievance and Appeals

Salt Lake City, UT 84131-0364

Online:

In person during normal business hours (8:00 a.m.–5:00 p.m. CST):

UnitedHealthcare Community Plan – KS

6860 West 115th Street

Overland Park, Kansas 66211

If you need help, call Member Services toll-free at 1-877-542-9238, TTY 711. Or online at myuhc.com > Appeals & Grievance Forms.

If someone else is going to file for you, we need your written permission. If you are a person with disabilities, you may call UnitedHealthcare Community Plan toll-free at 1-877-542-9238, TTY 711 to file a grievance. If you file a grievance, we will send you a letter within 10 calendar days telling you that we got your grievance. We will review your grievance. We will send our decision within 30 calendar days of getting your grievance. We will send you a letter with the decision.

What is an appeal?

An appeal is when you ask for a review of an adverse benefit determination. An adverse benefit determination is when we:

• Deny or limit a service you want
• Reduce, suspend or terminate payment for a service you are getting
• Fail to authorize a service in the required time
• Fail to respond to a grievance or appeal in the required time

How do I file an appeal with UnitedHealthcare Community Plan?

You or someone acting for you can file an appeal. You can request an appeal in the following ways:

Call Member Services toll-free 1-877-542-9238, TTY 711

In writing:

Grievance and Appeals

Salt Lake City, UT 84131-0364

In person during normal business hours (8:00 a.m.–5:00 p.m. CST):

UnitedHealthcare Community Plan – KS

6860 West 115th Street

Overland Park, Kansas 66211

You have sixty-three (63) calendar days from the sent date on the notice of adverse benefit determination to file an appeal. If you need help, call Member Services toll-free at 1-877-542-9238,TTY 711. Or online at myuhc.com > Appeals & Grievance Forms.

If someone else is going to file for you, we need your written permission.

If you file an appeal, we will send you a letter within 5 calendar days telling you that we got your appeal. We will review your appeal. The person who reviews your appeal will be a new person who has not previously reviewed it and will have the right level of clinical expertise. We will send you a decision within 30 calendar days of getting the appeal. The letter will tell the reason for our decision. We will tell you what to do if you don’t like the decision. When your appeal is decided, we will send you a written Notice of Appeal Resolution. This will have the date that the appeal was decided. It will say why we made the decision and how you can look over the reason for decision.

You can present evidence to support your appeal in writing. You may request a copy of your case file free of charge. You can also ask for and be given reasonable access to all documents, records, and other information relevant to your Adverse Benefit Determination. This is all free of charge. This information includes what information was used to determine your medical needs. It also includes the processes, strategies, or standards used in setting coverage limits.

If you would like to look at your case file before or during your appeal, call Member Services toll-free at 1-877-542-9238, TTY 711 to request your case file. It will take time for UnitedHealthcare to send your case files once you have requested them. Please make your request as soon as possible.A timely request will help you have the time you need to review before the resolution of your appeal.If your appeal is ruled in your favor, we will pay for those services.

What can I do if I need immediate care?

If you or your doctor wants a fast decision because your health is at risk, call Member Services toll-free at 1-877-542-9238, TTY 711 for an expedited review. UnitedHealthcare Community Plan will call you with our decision within 72 hours of getting your request. This time may be extended up to 14 calendar days if you ask for this or if we show a need for more information and the delay is in your interest. UnitedHealthcare will make reasonable efforts to provide oral notice of the delay.

Extensions are approved by the State of Kansas. You will get a notice of the reason for the extension if it is approved.

You will get a letter with our decision and the reason for our decision. We will tell you what to do if you don’t like the decision.

Continuation of care

You may be able to have your services continued during an appeal. Waiver benefits will continue until a decision is made if the member or their representative filed an appeal for waiver benefits within sixty-three (63) calendar days from the sent date on the notice of adverse benefit determination.

For non-waiver members, benefits continue until a decision is made only if the member or their representative asks for the benefits to be continued within 10 calendar days from the date the notice of adverse benefit determination is sent or before the notice of adverse benefit determination says your services will end. Services must have been ordered by an approved provider.

HCBS appeals

If your appeal about a reduction in HCBS waiver benefits is denied, you will not have to repay UnitedHealthcare Community Plan for the service(s) continued during the appeal, unless fraud is present.

Deemed exhaustion

Failure of United Healthcare to adhere to the notice and timing requirements listed above, means that the Member is deemed to have exhausted the appeals process and the Member may initiate a State Fair Hearing. In these situations, the Member will be notified in writing of the deemed exhaustion and next steps. Receipt of this notice is not required before a member can submit a request for a State Fair Hearing.

Provider’s external independent third-party review

A provider may appeal a denial by UnitedHealthcare Community Plan of a new healthcare service.If a provider appeals the denied service, members will receive a letter from the external reviewer that contains the external review decision. Following that, UnitedHealthcare Community Plan will issue a notice that includes your right to request a state fair hearing regarding the external reviewer’s decision within 33 calendar days of the date on the MCO’s notice of external review decision.

How do I file a State Fair Hearing request?

You or your representative can ask the Kansas Office of Administrative Hearings to review UnitedHealthcare Community Plan’s decision by asking for a State Fair Hearing.

• You must complete a UnitedHealthcare appeal before you can request a State Fair Hearing
• The Kansas Office of Administrative Hearings must get your request within 120 calendar days from the date of the Notice of Appeal Resolution, plus an additional 3 calendar days to allow for mailing/sending of the notice

There are three ways to ask for a State Fair Hearing:

1. Call UnitedHealthcare Community Plan toll-free at 1-877-542-9238, TTY 711

2. Complete the Request for Administrative Hearing form found online at https://www.oah.ks.gov/Home/Forms and mail it to:

Office of Administrative Hearings

1020 S. Kansas Ave.

Topeka, KS 66612

3. By fax — Office of Administrative Hearings 785-296-4848