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Commercial Eligibility, Enrollment, Transfers and Disenrollment - Capitation and/or Delegation Supplement, 2018 UnitedHealthcare Administrative Guide

Customers must meet all eligibility requirements established by the employer group and us. We may request evidence to validate eligibility requirements.

A member (or person otherwise eligible to enroll in a UnitedHealthcare product) may enroll an eligible child after presenting appropriate documentation.

To receive coverage, all care (except for emergency and urgently needed services) must be arranged in our service area by the designated PCP or medical group/IPA selected by the custodial parent or person having legal custody. A dependent eligible under a QMCSO does not need to reside within the service area to be eligible.

A dependent under the age of 26 and enrolled full-time as a student in a college may remain eligible when temporarily located outside our service area. To receive coverage, the designated PCP or medical group must provide or arrange all care (except for emergency and urgently needed services) in our service area.

Dependents of the subscriber are eligible for coverage, based on the subscriber’s benefit plan, and may include the following:

  • Spouse or common law spouse
  • Domestic partner
  • Unmarried child under the limiting age, such as :
    • Stepchildren
    • Children placed for adoption or legally adopted children
    • Grandchildren (only if subscriber has legal guardianship or the employer has purchased additional eligibility coverage)
    • Full-time students — proof of student status is required periodically for persons under the age of 26
    • Dependents with a physical or mental handicap, which have been identified as permanently disabled, and where the disabling condition occurred prior to reaching the limiting age

Certain disabled dependents, regardless of age, may have coverage under a subscriber’s benefit plan, provided:

  • They cannot engage in self-sustaining employment;
  • They depend on the subscriber for support; and
  • The disability occurred prior to the dependent reaching the employers limiting age.

The subscriber must submit proof of disabled dependents continuing eligibility, including the care provider’s diagnosis and prognosis, as outlined in the subscriber’s benefit plan. Further proof of incapacity and dependency may be required according to terms and conditions of a plan agreement and state law.

We acknowledge domestic partnerships the same as any spousal relationship for any employer group that accepts domestic partners under its benefit plan. Unless the subscriber’s benefit plan or state law dictates otherwise, covered domestic partners must satisfy the administrative requirements below.

  • A domestic partnership is defined as an ongoing, intimate and committed relationship between two persons of the same or opposite sex, who are not legal spouses:
    • Both partners must be 18 years or older (except as provided by California Family Code 297.1);
    • Neither party may be currently married to another party;
    • Neither may be related to the other by blood closer than would prohibit legal marriage;
    • Domestic partners do not include roommates, friends or other similar relationships;
    • Neither party has a different domestic partner now, nor has had a different domestic partner within the last six months, unless the previous domestic partnership was terminated by death;
    • Both partners agree to be economically responsible to third parties for their common welfare and financial obligations.

To enroll for membership, an applicant must complete a UnitedHealthcare enrollment form or an employer enrollment form approved by us. Some larger member accounts may provide open enrollment through electronic means rather than enrollment forms.

Newly eligible members may present a copy of the enrollment form as proof of eligibility. Care providers should make a copy of the enrollment form. If unable to verify member eligibility online or through our voice response systems, you should follow up with member service the next business day. The capitated medical group/IPA is responsible for making sure the contracted network of care providers accepts the enrollment form as temporary proof of eligibility.

We may receive enrollment/eligibility information from employer groups electronically or manually. We use this information to update member records.

Certain rural areas may have limited access to local care providers, and exceptions made to the guidelines governing enrollment.

Each employer group typically has an annual open enrollment period where current employees elect their health insurance choices for the following benefit year. Jan. 1 is a commonly used benefit start date, but many employers select different dates throughout the year. Plan codes change throughout the year on your eligibility reports.

Coverage begins at 12:01 a.m. on the effective date.

Members enrolled in some commercial benefit plans, such as HMO/MCO plans, are required to choose a primary care provider (PCP), as outlined in Chapter 3: Commercial Products: Primary Care Physicians (PCP) Selection.

Coverage of the subscriber’s newborn children begins at birth. The subscriber must submit an enrollment application to the employer group or UnitedHealthcare, as applicable, within 30 calendar days from the date of birth to continue coverage, unless the subscriber’s benefit plan dictates otherwise.

If the mother of the newborn is a dependent of the subscriber, but not the spouse, domestic partner or common law spouse of the subscriber, we will not cover any services provided to the newborn grandchild beginning upon delivery of the newborn unless coverage is specifically stated in the subscriber’s benefit plan.

Medical or facility services for surrogate mothers who are not our members are not covered.

California Commercial: State Knox-Keene regulations dictate eligible newborns coverage for the first 30 days beginning on date of birth. If the newborn is not enrolled as a dependent on the subscriber’s plan (mother’s or father’s), the newborn will have 30 days eligibility with the subscriber’s medical group/IPA for the 30 day period following birth. However, coordination of benefits may be applied as determined by the birthday rule.

Unless the subscriber’s benefit plan dictates otherwise:

If the mother (subscriber, spouse or domestic partner) is our member, the newborn will remain with the mother’s medical group/IPA until another PCP or medical group/IPA is selected following the 15/30 rules.

When the father is primary for the newborn per the birthday rule, his plan will cover the newborn for the first 30 days, even if the newborn is not enrolled on his plan.

Note: We cannot deny the enrollment or eligibility of a newborn covered under their parent’s health plan based on the following:

  • The child was born out of wedlock,
  • The child is not claimed as a dependent on the subscriber’s federal income tax return, or
  • The child does not reside with the subscriber.

In cases where both the mother’s insurance plan and the father’s insurance plan provide coverage for the newborn, coordination of benefit rules apply once the mother is discharged from the facility. When the father is primary for the newborn per the birthday rule, his plan will cover the newborn for the first 30 days, even if the newborn is not enrolled on his plan. The medical group/IPA must make sure they handle care coordination appropriately.

If both the mother and father of a dependent newborn are eligible under separate UnitedHealthcare benefit plans, we by the subscribers.

Any subsequent PCP or medical group/IPA transfer of a dependent newborn will follow the 15/30 rules.

Typically, coverage begins on the first day of physical custody if the subscriber submits an enrollment application to the employer group within 30 calendar days of physical custody of the child, unless the subscriber’s benefit plan dictates otherwise.

We may provide coverage for a surrogate when the surrogate is the subscriber or eligible dependent. Please refer to the UnitedHealthcare benefit plan. However, the newborn dependent(s) may not have coverage at birth. Surrogate cases need individual review. We make decisions on a case-by-case basis. We may issue newborn coverage denials to the facility in advance of the newborn’s birth. Please contact your Provider Relations representative if a surrogate case comes to your attention.

CA: Under California rescission rules, if UnitedHealthcare or the member’s care provider or medical group/IPA authorizes surrogate newborn care (beyond 30 days from birth), and the facility relies upon such authorization to render treatment, those claims must be paid.

We may seek recovery of our actual costs from a member who is receiving reimbursement for medical expenses for maternity services while acting as a surrogate.

A member may select a new medical group/IPA or PCP by calling Member Service or by accessing myuhc.com.

Members may change their PCP within the same medical group/IPA. The change is effective the first of the following month after the member calls requesting the change, unless the subscriber’s benefit plan dictates otherwise.

If a member requests a transfer out of the member’s medical group/IPA entirely, and the change request is received prior to or on the 15th of the month, we will change the member’s medical group/IPA effective the1st day of the following month. If the request to transfer to another medical group/IPA is received after the 15th of the month, the change is effective the first day of the 2nd month following receipt of the request.

If the member expresses dissatisfaction with the proposed effective date, we, in our discretion, may process the member’s request as a ‘Forward Primary Care Provider Change Request’, (if our contract with requested network care provider allows for a “retroactive” transfer). Per the contract, the network care provider may have the right to refuse to accept the member until the first day of the second month following receipt of request. Some care provider groups may only accept new members during an open enrollment period. If the member meets all eligibility requirements, the member will become effective the 1st day of the following month, even though the change request was received after the 15th of the month. If the 15th of the month falls on a weekend or holiday, we will allow transfer requests received on the first business day after the 15th to become effective the 1st day of the following month.

Transfers from one participating medical group/IPA to another, or PCP transfers initiated outside of member’s open enrollment period, will not be effective until the 1st day of the 2nd month following the member’s discharge from care, if at the time of the request for transfer or on the effective date of transfer, the member is currently:

  • Receiving inpatient care at an acute care facility;
  • Receiving inpatient care at a skilled nursing facility, at a skilled level;
  • Receiving other acute institutional care;
  • In the 3rd trimester of her pregnancy (defined as when the member reaches the 27th week of pregnancy); or
  • Experiencing a high-risk pregnancy (not applicable to California members).

We do not recommend the member change PCPs while an inpatient in a facility, SNF, or other medical institution, or undergoing radiation therapy or chemotherapy, as a change may negatively affect the coordination of care.

Members may retroactively change their medical group/IPA or PCP within the same month, in the following instances:

  • The member calls to request a change within 30 calendar days of their effective date and has not received services with the originally assigned care provider; or
  • The member calls to request a change within 30 calendar days due to a household move over 30 miles, and the member has not received services with the originally assigned care provider.

If the member received services during the current month from you, other than the month requested, a current month change will not be permitted.

If the member’s medical group/IPA, PCP, or facility, is terminated, we will give prior written notice to members as applicable or when required by state or federal law. In such event, the member may qualify for continuation of care as outlined in the Continuity of Care section of this supplement. For individual physician terminations, the medical group/IPA is responsible for providing the notice in the following circumstances:

  • PCP terminations in medical group/IPAs where medical group/IPA assigns members to the PCPs; and
  • All specialist terminations.

Each commercial member will be provided with at least 30 calendar days (exception: 60 calendar days in California) to select another medical group, IPA, PCP or facility.

Each Medicare member will be provided with at least 14 calendar days (exception: 60 calendar days in California) to select another medical group/IPA, PCP, or facility within the member’s current medical group/IPA. The member will receive a new health care ID card prior to the first of the month in which the transfer is effective.

When a member is in need of care and it is determined the member’s PCP has terminated without proper notice, we will transfer the member to another PCP, within the same medical group/IPA with an effective date retroactive to the first of the current month.

 

The medical group/IPA knows and agrees that UnitedHealthcare has the right to move a medically stable member to another medical group/IPA or care provider, if due to a strained relationship between the medical group/ IPA and member.

For instance, a member may refuse to accept a medical group/IPA’s recommended treatment, counsel or procedure. The medical group/IPA may regard such refusal to accept its recommendations as incompatible with the continuance of the care provider-member relationship and as obstructing the provision of proper medical care. If a member refuses to accept the recommended treatment, counsel or procedures, and the medical group/IPA believes no professionally acceptable alternatives exist, the member is advised.

The medical group/IPA may request UnitedHealthcare to change a member to a different medical group/IPA if the care provider-member relationship is materially damaged by the member’s refusal to accept recommended treatment, counsel or procedure. We will evaluate such request considering the member’s best interests and the geographic accessibility of another medical group/IPA. If we approve the request for transfer, we shall request the member to select another medical group/IPA within 30 calendar days. If the member fails to select another medical group/IPA, we shall designate another medical group/ IPA on the member’s behalf. If , however, no professionally acceptable alternatives exist, neither UnitedHealthcare nor the medical group/IPA shall be responsible to provide or arrange for the medical care or pay for the condition under treatment.

Potential areas of concern for requesting removal of a member from the medical group/IPA include:

  • Repeated disruptive behavior or dangerous behavior exhibited in the course of seeking/receiving care;
  • Failure to pay required copayments (minimum dollar amount of $200 outstanding); or
  • Fraudulently applying for any UnitedHealthcare benefits.

If you receive notification of a member’s intent to sue, please tell your physician advocate.

Send copies of all notification letters, request for removal and supporting documentation to your provider advocate.

After we receive of a completed “Incident Report for Removal of Members” and related documentation, we will respond to the member and copy the PCP or medical group/IPA on all correspondence.

Level I

Criteria

Demanding a payment from medical group/

IPA for non-authorized services;

Minor disruptive behavior*

Failure to pay required copayments**

Three or more missed appointments, within six consecutive-months without 24-hour prior notice.

1st Occurrence:

Medical group/IPA must counsel with and write to member in certified letter expressing such behavior is unacceptable;

Discussions need documentation. Send copies to UnitedHealthcare, which will send warning letter outlining behavior and possible consequences.

2nd Occurrence:

Medical group/IPA must counsel with and send second letter to member expressing concern regarding their unacceptable behavior;

Send copies to UnitedHealthcare, which will send warning letter outlining continued behavior and possible consequences.

3rd Occurrence:

Send UnitedHealthcare request to immediately remove a subscriber/member from the medical group/IPA. We will review the medical group/IPA documentation, which outlines continued unacceptable behavior.

Level II

Criteria

Refusal to follow recommended treatment, or procedures by care provider resulting in deterioration of member’s medical condition;

Disruptive behavior, verbal threats of bodily harm towards medical group/IPA personnel and/or other members, provided the conduct is not a direct result of the member’s medical condition or prescribed medication.+

1st Occurrence:

Medical group/IPA must counsel with and write to member in certified letter expressing such behavior is unacceptable;

Discussions will need documenting. Send copies to UnitedHealthcare, which will send warning letter outlining behavior and possible consequences.

2nd Occurrence:

Send UnitedHealthcare a request to immediately remove subscriber/member from the medical group/IPA. UnitedHealthcare will review the medical group/IPA documentation outlining continued unacceptable behavior.

Level III

Criteria

Member fraudulently applies for any UnitedHealthcare benefits;

Dangerous behaviors exhibited in the course of seeking or receiving care provided the conduct is not a direct result of the member’s medical condition or prescribed medication.

Need an eyewitness who is willing to formally document the incident in writing.

1st Occurrence:

Medical group/IPA requests immediate removal of subscriber/member from medical group/IPA. Incident must be, formally documented by medical group/IPA;

Send written notification to member in a certified letter. Mail copies of documentation and member letter to UnitedHealthcare for review.

2nd Occurrence:

Send UnitedHealthcare a request to immediately remove subscriber/member from the medical group/IPA. UnitedHealthcare will review the medical group/IPA documentation outlining continued unacceptable behavior.


* Minor disruptive behavior: unruly behavior, use of abusive and/or profane language directed towards medical group/IPA and/or other members.
** UnitedHealthcare West will not consider the removal of a member unless the unpaid copayment balance exceeds $200.00.
+ Disruptive behavior: physical or verbal threat of bodily harm towards medical group/IPA personnel and/or other members or property, and/or use of unacceptable behavior relative to drug and/or alcohol misuse.
# Dangerous behavior such as; attempted physical abuse, display of weapon or damage to property, use of unacceptable behavior relative to drug and/or alcohol misuse, and/or chronic demands for unreasonable services.