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Children with Special Health Care Needs Frequently Asked Questions
What is Medicaid?
Medicaid is a program for people with low income who meet certain eligibility requirements and programs can vary from state-to-state.
What is Medicaid Expansion?
The Affordable Care Act expanded Medicaid to include individuals adults (19-64 years old) without any dependent children or disability that make to less than $15,654 a year or less than $1,305 per month.
What is the Affordable Care Act (ACA)?
The Affordable Care Act expands access to quality and affordable health coverage for millions of people. Signed into federal law by President Barak Obama in 2010, the ACA guarantees health coverage regardless of income level, work situation, or previous health conditions.
What is HealthSourceRI?
HealthSourceRI is Rhode Island’s health insurance marketplace. People are able to directly apply for health coverage directly on the website www.healthsourceri.com or, if you need assistance to apply, make an appointment with a Navigator at 855-840-4774.
Which services require prior authorization?
Some services and prescription drug medications may require prior authorizations. It is the responsibility of your doctor to get prior authorization when required.
Where do I get prescriptions filled?
The RIte Care and Rhody Health Partners Directory of Physicians and other Health Care Providers lists pharmacies where you can get your prescriptions. Just bring your prescription and show your identification card at a participating pharmacy to get your prescription filled. Your Physician and Health Care Provider Directory is part of your member materials packet. Many pharmacies stay open 24 hours a day so you can get a prescription filled in the middle of the night, if you need to.
How do I get over the counter medications?
Your UnitedHealthcare clinician needs to write an order on their prescription pad for over-the counter medications. Just bring the prescription and bring your UnitedHealthcare identification card to a participating pharmacy to get your OTC prescription filled. Examples of over-the counter-medications include aspirin, cough syrup, condoms and much more. These medications are available to you at no cost.
What is a formulary?
A formulary is a list of medications that UnitedHealthcare will pay for when ordered by your doctor. UnitedHealthcare has a large formulary. Some drugs require that your doctor get prior approval by UnitedHealthcare. Your doctor may contact us for more information about coverage or visit our website for our formulary.
How is the RIte Care and Rhody Health Partners/Children with Special Health Care Needs Formulary (Prescription benefit) different?
All Medicaid members must use generic drugs first. Generic drugs may require prior authorization. There are a limited number of brand name drugs that will be covered. These will be limited to certain classes (or types) of drugs. Additionally, some of these may require prior authorization by UnitedHealthcare. If you feel you that you are unable to take the generic medication, please contact your provider. Health plan providers are aware of the criteria for approval of brand name drug coverage.
How do I get injectable medications?
- Injectable medications are covered under the medical benefit. Your doctor can make arrangements to have the injectable medication delivered, either to his/her office or your home. In some instances your doctor will write you a prescription for injectable medication (i.e. insulin), which can be filled at a pharmacy.
Do I have co-pays for prescriptions?
Most UnitedHealthcare RIte Care and Rhody Health Partners members do not have copays. Check your benefit summary to see if you have a co-pay.
How do I access my mental health benefits?
To access your Behavioral Health benefits please call Optum Behavioral Health at 800-435-7486 (TTY: 711) and an intake specialist will assist you. Or visit the website.
What if a doctor, lab or clinic sends me a bill?
if you received a bill for covered services, we will help you resolve the issues. This includes emergency services received out-of area but within the United States and territories. Call Member Service at 1-800-587-5187 (TTY 711).
You may also send the bill to:
UnitedHealthcare Community Plan
Attention: Member Appeals
P.O. Box 31364
Salt Lake City, UT 84131
Do I need to let UnitedHealthcare know if I become pregnant or have a baby?
Yes. First contact your local Department of Human Service (DHS) office. Second call Member Services at 1-800-587-5187 (TTY:711), open Monday – Friday 8:00 a.m. – 7:00 p.m.
Are there a minimum number of hospital days that UnitedHealthcare will cover if I have a baby?
Yes. UnitedHealthcare is required by law to cover a minimum hospital stay of 48 hours after a vaginal birth and 96 hours after a caesarean birth, unless the mother requests an early discharge.
Do I have to pay a premium?
RIte Care Members: Beginning January 2014, families will no longer need to pay a monthly premium to keep children enrolled.
What if my children or I have other health insurance?
If you have RIte Care the other health insurance company will pay your health care bills first. When you receive care, always show both cards (your insurance card and your UnitedHealthcare RIte Care Insurance card.) If you have Rhody Health Partners or RIte Care and become eligible for other insurance please notify the Rhode Island Department of Human Services.
What if my family size changes?
Notify your local Department of Human Service office and Member Services at 1-800-587-5187 or (TTY: 711) Monday – Friday 8:00 a.m. – 7:00 p.m.
Does the Health Plan require that I get a second opinion for any services?
No. UnitedHealthcare does not require you to get a second opinion for covered services. However a second opinion is available to you at no cost for all medical, surgical, and other healthcare covered services.
What benefits are not covered by my health plan?
The following services are not covered by UnitedHealthcare:
- Experimental procedures, except where a state mandate for coverage exists
- Abortion services, except to preserve the life of the women or in case of rape or incest.
- Private rooms in hospitals (unless medically necessary)
- Cosmetic surgery
- Infertility treatment services
- Sexual and erectile dysfunction medications
Services outside Rhode Island are not covered unless the provider is participating with UnitedHealthcare New England's Medicaid plan, or with an authorization if a covered benefit is not available in network.
RIte Care and Rhody Health Partners Members:
Services outside of United States territory (emergency and non-emergency) are not covered. Emergency Services are covered within the 50 United States. If you have an emergency go to the closest emergency room.
What is our mailing address?
UnitedHealthcare Community Plan
475 Kilvert Street
Warwick, RI 02886
Attn: Medicaid Program
What documents will I need when I apply for Medicaid through HealthSourceRI?
When you apply for Medicaid through HealthSourceRI, you will need the following information:
- Information about household members (name date of birth, Social Security number)
- Employer name and income information (pay stubs)
- Previous Tax Returns (w2 form, 1099 form)
- Proof of citizenship (or document numbers for legal immigrants)
- Bank Statements
Children with Special Health Care Needs
- Frequently Asked Questions
- Links to Health Information