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UnitedHealthcare Community Plan FAQ
메디케이드란 무엇인가?
메디케이드는 자격 요건을 충족하는 저소득자를 위한 프로그램이며 주에 따라 적용 방법이 달라질 수 있습니다. 메디케어는 65세 이상의 노인, 장애인 또는 말기 신장병을 앓고 있는 사람들을 위한 연방정부의 건강 보험 프로그램입니다. 메디케어 자격 요건은 수입을 바탕으로 하지 않으며 기본 보상 범위는 주마다 동일합니다.
메디케이드를 신청할 때 필요한 서류는 무엇입니까?
메디케이드를 신청할 때는 신청서를 작성해 주시면 됩니다. 또한 다음과 같은 여러 문서도 필요합니다.
- 가족 구성원에 대한 정보(이름, 생일 및 사회 보장 번호)
- 임대료 또는 융자금 정보
- 지출 내역(공과금, 탁아 등)
- 자동차 정보
- 계좌 거래 내역서
- 수입(급여 명세서)
- 현재의 의학적 건강 상태를 나타내는 장애 또는 의료 기록 증명서
- 최근 병원비 청구서
- 시민권 보유 증명서
- 요청되는 추가 정보
How can I reach Customer Service?
Call 1-800-690-1606. 이 무료 전화번호로 문의하십시오. TTY users call 1-800-884-4327. This number requires special telephone equipment. Hours of Operation are from 8 A.M to 5 P.M., Monday – Friday during your time zone.
처방약 혜택 설명서(EOB)란 무엇입니까?
혜택 설명서는 매월 처방약 보상 범위를 이용할 때 받게 되는 문서입니다. 이 문서는 여러분이 처방약에 지불한 총 금액과 United Healthcare에서 처방약에 대해 지불한 총 금액을 알려 줍니다. United Healthcare에서 제공하는 혜택을 이용하는 매달, 메일로 혜택 설명서를 받게 됩니다.
How do I keep my membership record up to date?
Please call Customer Service at 1-800-690-1606 (Calls to these numbers are free),TTY users call 1-800-884-4327 if there are any changes to your name, address, phone number or changes in health insurance coverage from other sources such as from your employer, spouse’s employer, worker’s compensation, Medicaid, or liability claims such as claims from an automobile accident. 운영 시간: 8 A.M to 5 P.M., Monday – Friday during your time zone.
How do I choose a PCP?
You may choose any plan provider to be your PCP. Plan Providers are listed in the provider directory or you may call Customer Service for assistance in finding a plan provider.
How can I switch to another PCP?
You may change your PCP for any reason, at any time. Customer Service will help make sure that the PCP you want to switch to is a participating provider with UnitedHealthcare Community Plan for Families. They will also check to be sure the PCP you want to switch to is accepting new patients.
What if my doctor or other provider leaves your plan?
Sometimes a PCP, specialist, clinic, hospital or other plan provider you are using might leave the Plan. If this happens, you will have to switch to another provider who is part of our Plan. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services.
What happens if I am traveling out of the UnitedHealthcare Community Plan for Families Service area and need care?
You may get care when you are outside the service area. You will usually pay higher costs for the care because you will get your care from non-plan providers, but you won’t pay extra if you are getting care for a medical emergency. If you have questions about your medical costs when you travel, please call Customer Service. Call 1-800-690-1606. 이 무료 전화번호로 문의하십시오. TTY users call 1-800-884-4327. This number requires special telephone equipment. Hours of Operation are from 8 A.M to 5 P.M., Monday – Friday during your time zone.
How is a "medical emergency" defined?
A "medical emergency" is when you reasonably believe that your health is in serious danger – when every second counts. A medical emergency includes severe pain, a bad injury, a serious illness, or a medical condition that is quickly getting much worse.
What happens if I need a prescription filled or refilled outside my plan's service area?
We have network pharmacies outside of the service area where you can get your drugs covered as a member of our Plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Before you fill your prescription in these situations, call Customer Service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for a valid reason, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription.
If I have a prescription filled outside my plans service area for a good reason, can I get reimbursed?
You may ask us to reimburse you for our share of the cost by submitting a claim form. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay will help you qualify for catastrophic coverage.
Note: If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.
How do I get reimbursed for prescriptions filled outside my plans service area when there was a valid reason?
When you return home, simply submit your claim and your receipt to the following address:
Prescription Solutions
P.O. Box 6082
Cypress, 캘리포니아 90630-0082
If you submit a paper claim asking us to reimburse you for a prescription drug that is not on our formulary or is subject to coverage requirements or limits, your doctor may need to submit additional documentation supporting your request.
보험적용 의약품 목록이란 무엇입니까?
보험적용 의약품 목록은 플랜에서 보장하는 의약품 목록입니다. 의약품이 필요한 경우 보통 보험적용 의약품 목록에 기재된 의약품을 보장하고, 처방약은 네트워크 의약품에서 제공하고, 기타 보장 규칙을 준수합니다. 특정 처방약의 경우 보장을 받으려면 추가 요건이 필요하거나 보장 범위를 제한할 수 있습니다.
How are drugs on the formulary selected?
The drugs on the formulary are selected by our Plan with the help of a team of health care providers. We select the prescription therapies believed to be a necessary part of a quality treatment program. Both brand-name drugs and generic drugs are included on the formulary. A generic drug has the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs.
Not all drugs are included on the formulary. In some cases, the law prohibits coverage of certain types of drugs. In some cases, we have decided not to include a particular drug.
보험적용 의약품 목록의 약품은 어떻게 찾습니까?
You may call Customer Service to find out if your drug is on the formulary or to request a copy of our formulary. 또한 웹 사이트를 방문하여 보장되는 의약품에 대한 최신 정보를 얻을 수도 있습니다.
How much will I have to pay for my prescription?
Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your coinsurance/co-payment depends on which drug tier your drug is in.
What if my drug isn't on the formulary?
If your prescription isn’t listed on the formulary, you should first contact Customer Service to be sure it isn’t covered.
If Customer Service confirms that we don’t cover your drug, you have three options:
You may ask your doctor if you can switch to another drug that is covered by us.
You may ask us to make an exception (which is a type of coverage determination) to cover your drug. See your Evidence of Coverage (member handbook) to learn more about how to request an exception.
You can pay out-of-pocket for the drug and request that the Plan reimburse you by requesting an exception (which is a type of coverage determination). This doesn’t obligate the Plan to reimburse you if the exception request isn’t approved. If the exception isn’t approved, you may appeal the Plan’s denial. Please see your Evidence of Coverage for more information on how to request an appeal.
In some cases, we will contact you if you are taking a drug that isn’t on our formulary. We can give you the names of covered drugs that also are used to treat your condition so you can ask your doctor if any of these drugs are an option for your treatment.
What are network pharmacies?
A network pharmacy is a pharmacy that has a contract with us to provide your covered prescription drug. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Once you go to one, you aren’t required to continue going to the same pharmacy to fill your prescription; you may go to any of our network pharmacies.
What are "covered drugs"?
"Covered drugs" means all of the outpatient prescription drugs that are covered by our Plan. Covered drugs are listed in our formulary.
What should I do if I have a medical emergency?
If you have a medical emergency:
- Get medical help as quickly as possible. Call 911 for help or go to the nearest emergency room, hospital, or urgent care center. You don’t need to get approval or a referral first from your PCP or other plan provider.
- Make sure that your PCP knows about your emergency, because your PCP needs to be involved in following up on your emergency care. - You or someone else should call to tell your PCP about your emergency care as soon as possible, usually within 48 hours.
긴급하게 필요한 치료는 어떻게 받습니까?
If, while temporarily outside the Plan’s service area, you require urgently needed care, then you may get this care from any provider. The plan is obligated to cover all urgently needed care at the cost-sharing levels that apply to care received within the Plan network.
What if I use non-plan providers to receive services that are "covered"?
Except in limited cases such as emergency care, urgently needed care when our network is not available, or out of service area dialysis, you must obtain covered services from network providers for the services to be covered. If you get non-emergency care from non-network providers without prior authorization, you must pay the entire cost yourself.
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