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Not all health insurance is created equal. That’s why we’re proud to offer low- or no-cost Medicaid plans and even more benefits with our dual health plans.
United Healthcare Community Plan Provider Enrollment
Dual health plans are for people who have both Medicaid and Medicare. Dual plans cover doctor visits, hospitalization and prescription drugs. They offer more benefits and features than Original Medicare. You’ll also keep all your Medicaid benefits.
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Medicaid provides health insurance for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. In some states, Medicaid covers all low-income adults below a certain income level.
The Children’s Health Insurance Program (CHIP) provides health coverage to eligible children through both Medicaid and separate CHIP programs.
The exchange refers to the Health Insurance Marketplace, where Affordable Care Act (ACA) health care plans are sold. You may also have heard terms like ObamaCare, BidenCare, or Individual and Family Plans (IFPs) to refer to these plans, which are all health insurance plans that people can buy themselves instead of being through the employer or through a governmental government. program such as Medicare or Medicaid.
Answer a few quick questions to see what type of plan may be right for you.
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Medicaid redetermination is also called Medicaid renewal or Medicaid recertification. It all means the same thing. This is when people on Medicaid are required to prove that they still qualify for Medicaid in their state. Some people may have already learned that they need to renew their Medicaid. Others may receive a notification soon.
The exact date of Medicaid eligibility renewal depends on your state. State agencies will contact you by mail and/or email and you will be given a date by which the updates must be completed. Search for your health plan using your zip code or drop-down menu to learn more about any actions you should take. Powered by UnitedHealthcare Dual Complete® Launch Date – January 1, 2018 BH1188_ United Behavioral Health operating under the Optum brand
UnitedHealthcare Dual Complete® Behavioral Health Plan Features and Benefits: Behavioral Health Benefits Eligibility 2018 Sample Member ID Cards Cost-Sharing Clinic Program Requirements: Authorizations and Contact Information Caregiver Training Model Submitting Claims: Information on sending EPS Information requests
SNP is a Medicare Advantage (MA) coordinated care plan that provides targeted care and services to people with unique needs. There are three types of SNP plans: Chronic SNP: For members with severe or disabling chronic conditions as specified by the Centers for Medicare and Medicaid Services (CMS) Institutional SNP: For members who require a nursing home level of care Dual SNP : For members eligible for Medicare and Medicaid
Changes To Pennsylvania’s Medical Assistance Plans
SNPs must follow CMS regulations and cover all Medicare Part A (hospital stay) and Part B (doctor’s office) benefits and must include Medicare Part D (pharmacy) coverage SNPs must offer clinical programs and specialty expertise to serve the target population UnitedHealthcare Dual Complete® Medicare Advantage plans will reimburse eligible behavioral health claims according to your Optum agreement for all payers
DSNPs must: Limit enrollment to Medicaid (dual eligible) beneficiaries Medicare-Medicaid enrollees Offer Part D benefits Offer targeted clinical programs, benefits, and services Report additional SNP values. to qualify for a special election period (SEP)
Member Eligibility Who is eligible: Must have Medicare Parts A & B residents in the plan. Service Area Must not have end-stage renal disease (ESRD) – generally: Must have a certain level of Medicaid eligibility to participate Eligibility level defined by local Medicaid agency UnitedHealthcare performs a Medicaid eligibility check prior to enrollment for ensure appropriate verification for each plan type prior to program start date.
Behavioral Health Benefits The United Healthcare Dual Complete® Medicare Advantage Program offers a full suite of behavioral health benefits. These services must be provided by a Medicare-eligible provider: Acute inpatient mental health and substance use disorder (SUD) hospital (Follow Medicare hospital days rules) Freestanding inpatient psychiatric facility (190 days per lifetime) Partial hospitalization MH/SUD (PHP) MH/SUD Intensive Outpatient (IOP) Electroconvulsive Therapy (ECT) Transmagnetic Stimulation (TMS) Psychological Testing Standard Home Health/Routine Outpatient (CPT Codes) We use Medicare Coverage Summaries, if available, for determining MNC.
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Summary: Network providers provide Medicare services to DSNP members who are eligible Medicare beneficiaries. UnitedHealthcare Dual Complete Medicare Advantage is the member’s primary insurance. Medicaid is secondary
Check eligibility and benefits Link > eligibilityLINK application If you are not yet registered, go to UHCprovider.com and select “New User” to start registration Call the provider services on the back of your member’s ID card Always check your benefits before providing services to a UnitedHealthcare Community Plan Member Before providing services, please verify Member eligibility.
Member ID Card – RR Card (Regional PPO) 1 2 4 5 3 Group Number: Two-digit State Abbreviation and Pharmacy DSNP: Medicare Rx Medicare Reference – Product name and Medicare limits apply. 4. Provider Reference: Online Resources Available at UnitedHealthcareonline.com 5. Medicare Reference: Medicare Community Plan * Sample ID cards are for illustration only. Actual cards may vary.
Member ID Card – HMO SNP Card 1 2 4 5 3 Group Number: Two-digit State Abbreviation and Pharmacy DSNP: Medicare Rx Medicare Reference – Product name and Medicare limits apply. 4. Provider Reference: Online Resources Available at UnitedHealthcareonline.com 5. Medicare Reference: Medicare Community Plan * Sample ID cards are for illustration only. Actual cards may vary.
Rhode Island Medicaid Health Plans
Member Cost Sharing Cost sharing for all members in UnitedHealthcare Dual Complete® depends on members’ dual eligibility level: Some members may have out-of-pocket costs for premiums, copays, and coinsurance All members will have either full or partial Medicaid coverage. Policy A care provider may not bill, charge, collect a deposit from, seek payment or reimbursement from, or have any recourse against: Any UnitedHealthcare Dual Complete® Medicare Advantage plan member who is eligible for both Medicare and and for Medicaid. Member representative or UnitedHealthcare Dual Complete® Medicare Advantage Organization for Medicare Part A and B cost sharing, such as copayments, deductibles, and coinsurance, when the state Medicaid agency is responsible for paying those amounts
Reimbursement Stream Primary Insurer – Secondary Insurer Full Full – Medicaid HMO-SNP Provider Payment: 80% Coverage, Payable Based on Contracted Medicare Advantage Payment Appendix RPPO-SNP (INN):* 80% Coverage, Payable Based on Contracted Medicare RPPO-SNP Benefit Supplement (OON): 60% of current Medicare reimbursement rate HMO-SNP: 20% coinsurance. The payment from the primary insurer may be greater than the RPPO-SNP (INN) Medicaid Allowance:* Remaining coinsurance amount. Payment from primary insurer may be higher than RPPO-SNP (OON) Medicaid Allowance: 40% coinsurance. The payment from the primary insurer may be higher than the final reimbursement allowed by Medicaid. Providers may not balance the bill or attempt to collect additional reimbursement from DSNP members NOTE: Example of possible reimbursement – actual will depend on exact services provided.
Prior Authorization Prior authorization is required per CMS guidelines (see Summaries of Medicare Coverage) and Optum Level of Care (LOC) for Medicare members: Find the Optum LOC guidelines by going to providerexpress.com > Clinical Resources tab > Guidelines/Policies and Manuals > Level Care Guidelines and/or Selection of Medicare Coverage Summaries Find the Optum Network Handbook by going to providerexpress.com > Clinical Resources tab > Guidelines/Policies and Handbooks > Optum Network Handbook
Prior Authorization and Provider Contact Information Online: UHCprovider.com/Link Phone: Weekdays 8 a.m. – 6 p.m., available 24 hours a day for emergencies Check the phone numbers on the back of your Member ID card for the correct phone numbers
Unitedhealthcare Dual Complete® Plan And Benefits
Link is your gateway to UnitedHealthcare’s online tools. Use Link apps to help simplify daily administrative tasks: Check member eligibility Submit a claims reassessment Review benefit coordination information View care opportunities for Members To register for Link, log in to UHCprovider.com using your ID .Optum or click “New User” if they do not have an Optum ID. For more information, click on “Link” under “Learn more about Link”.
Reminder: Model of Care Training The Centers for Medicare and Medicaid Services (CMS) requires all providers of care who treat patients in a Special Needs Plan (SNP) to complete annual Model of Care (MOC) training: We offer training annually SNP MOC as a pre-recorded session that takes approximately 10 minutes to complete. For new plans launching January 1, 2018, providers will be required to complete training by October 1, NOTE: New 2018 training will be released during Q UHCprovider.com > Menu > Resource Library > Training: Scroll to down to Special Needs Plan Template 2017 Caregiver Training Registration required To learn more, contact or
For electronic submission, the payer ID can be found on the Member’s ID card. See eSolutions and your health plan for another payer ID. Application Link – clearingsLink Clearinghouse of your choice: If you receive 835 Electronic Remittance Advice (ERAs) through a provider, please ask them to sign you up for 835 through the OptumInsight Connectivity Director. To learn more, please contact your supplier or call Electronic Data Interchange (EDI) at
You can send paper claims to the claims address on the back of your Member ID card. Filing on standard time:
