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UnitedHealthcare Community Plan Glossary

A

  • Activities of Daily Living

    The things people do on a normal day, such as eating, using the toilet, getting dressed, bathing, or brushing the teeth.

  • Adverse Benefit Determination

    Any decision to deny a service authorization request or to approve it for an amount that is less than requested.

  • Appeal

     A way for you to challenge an adverse benefit determination (such as a denial or reduction of benefits) made by UnitedHealthcare Community Plan if you think we made a mistake. You can ask us to change a coverage decision by filing an appeal.

B

  • Balance Billing

    A situation when a provider (such as a doctor or hospital) bills a person more than UnitedHealthcare Community Plan's cost-sharing amount for services. We do not allow providers to "balance bill" you. Call Member Services if you get any bills that you do not understand.

  • Brand Name Drug

    A prescription drug that is made and sold by the company that originally made the drug. Brand name drugs have the same ingredients as the generic versions of the drugs. Generic drugs are made and sold by other drug companies.

C

  • Care Coordination

    A person-centered individualized process that assists you in gaining access to needed services. The Care Coordinator will work with you, your family members, if appropriate, your providers and anyone else involved in your care to help you get the services and supports that you need.

  • Care Coordinator

    One main person from UnitedHealthcare Community Plan who works with you and with your care providers to make sure you get the care you need.

  • Care Plan

    A plan for what health and support services you will get and how you will get them.

  • Care Team

    A care team may include doctors, nurses, counselors, or other health professionals who are there to help you get the care you need. Your care team will also help you make a care plan.

  • Centers for Medicare & Medicaid Services (CMS)

    The federal agency in charge of Medicare and Medicaid programs.

  • Complaint

    A written or spoken statement saying that you have a problem or concern about your covered services or care. This includes any concerns about the quality of your care, our network providers, or our network pharmacies. The formal name for “making a complaint” is "filing a grievance."

  • Copayment

    Copayments (copays) are a dollar amount that you pay to the doctor at your visit.

  • Coverage Decision

    A decision about what benefits we cover. This includes decisions about covered drugs and services or the amount we will pay for your health services.

  • Covered Drugs

    The term we use to mean all of the prescription drugs covered by UnitedHealthcare Community Plan.

  • Covered Services

    The general term we use to mean all of the health care, long-term services and supports, supplies, prescription and over-the-counter drugs, equipment, and other services covered by UnitedHealthcare Community Plan.

D

  • Durable Medical Equipment

    Certain items your doctor orders for you to use at home. Examples are walkers, wheelchairs, or hospital beds.

E

  • Emergency Medical Condition

    An emergency means your life could be threatened or you could be hurt permanently (disabled) if you don't get care quickly. If you are pregnant, it could mean harm to the health of you or your unborn baby.

  • Emergency Medical Transportation

    Your condition is such that you are unable to go to the hospital by any other means but by calling 911 for an ambulance.

  • Emergency Room Care

    A hospital room staffed and equipped for the treatment of people that require immediate medical care and/or services.

  • Excluded Services

    Services that are not covered under the Medicaid benefit.

F

  • Fair Hearing

    See State Fair Hearing. The process where you appeal to the State on a decision made by us that you believe is wrong.

  • Fee-for-Service

    The general term used to describe Medicaid services covered by the Department of Medical Assistance Services (DMAS).

G

  • Generic Drug

    A prescription drug that is approved by the federal government to use in place of a brand name drug. A generic drug has the same ingredients as a brand name drug. It is usually cheaper and works just as well as the brand name drug.

  • Grievance

    A complaint you make about us or one of our network providers or pharmacies. This includes a complaint about the quality of your care.

H

  • Habilitation Services and Devices

    Services and devices that help you keep, learn, or improve skills and functioning for daily living.

  • Health Insurance

    Type of insurance coverage that pays for health, medical and surgical expenses incurred by you.

  • Health Plan

    An organization made up of doctors, hospitals, pharmacies, providers of long-term services, and other providers. It also has Care Coordinators to help you manage all your providers and services. They all work together to provide the care you need.

  • Health Risk Assessment

    A review of a patient’s medical history and current condition. It is used to figure out the patient's health and how it might change in the future.

  • Helpline

    An Enrollment Broker that DMAS contracts with to perform choice counseling and enrollment activities.

  • Home Health Aide

    A person who provides services that do not need the skills of a licensed nurse or therapist, such as help with personal care (like bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

  • Home Health Care

    Health care services a person receives in the home including nursing care, home health aide services and other services.

  • Hospital Outpatient Care

    Care or treatment that does not require an overnight stay in a hospital.

  • Hospitalization

    The act of placing a person in a hospital as a patient. 

L

  • List of Covered Drugs (Drug List)

    A list of prescription drugs covered by UnitedHealthcare Community Plan. UnitedHealthcare Community Plan chooses the drugs on this list with the help of doctors and pharmacists. The Drug List tells you if there are any rules you need to follow to get your drugs. The Drug List is sometimes called a "formulary."

M

  • Medicaid (or Medical Assistance)

    A program run by the federal and the state government that helps people with limited incomes and resources pay for long-term services and supports and medical costs. It covers extra services and drugs not covered by Medicare. Most health care costs are covered if you qualify for both Medicare and Medicaid.

  • Medically Necessary

    This describes the needed services to prevent, diagnose, or treat your medical condition or to maintain your current health status. This includes care that keeps you from going into a hospital or nursing facility. It also means the services, supplies, or drugs meet accepted standards of medical practice or as necessary under current Virginia Medicaid coverage rules.

  • Member Services

    A department within UnitedHealthcare Community Plan responsible for answering your questions about your Membership, benefits, grievances, and appeals.

  • Model of Care

    A way of providing high-quality care. The model of care includes care coordination and a team of qualified providers working together with you to improve your health and quality of life.

N

  • Network

    "Provider" is the general term we use for doctors, nurses, and other people who give you services and care. The term also includes hospitals, home health agencies, clinics, and other places that provide your health care services, medical equipment, and long-term services and supports. They are licensed or certified by Medicaid and by the state to provide health care services. We call them "network providers" when they agree to work with the UnitedHealthcare Community Plan and accept our payment and not charge our Members an extra amount. While you are a Member of UnitedHealthcare Community Plan, you must use network providers to get covered services. Network providers are also called "plan providers."

  • Network Pharmacy

    A pharmacy (drug store) that has agreed to fill prescriptions for UnitedHealthcare Community Plan Members. We call them “network pharmacies” because they have agreed to work with UnitedHealthcare Community Plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

  • Non-participating Provider

    A provider or facility that is not employed, owned, or operated by UnitedHealthcare Community Plan and is not under contract to provide covered services to Members of UnitedHealthcare Community Plan.

  • Nursing Facility

    A medical care facility that provides care for people who cannot get their care at home but who do not need to be in the hospital. Specific criteria must be met to live in a nursing facility.

O

  • Out-of-Network Provider or Out-of-Network Facility

    A provider or facility that is not employed, owned, or operated by UnitedHealthcare Community Plan and is not under contract to provide covered services to Members of UnitedHealthcare Community Plan.

P

  • Participating Provider

    Providers, hospitals, home health agencies, clinics, and other places that provide your health care services, medical equipment, and long-term services and supports that are contracted with UnitedHealthcare Community Plan. Participating providers are also "in-network providers" or "plan providers."

  • Physician Services

    Care provided to you by an individual licensed under state law to practice medicine, surgery, or behavioral health.

  • Prescription Drug Coverage

    Prescription drugs or medications covered (paid) by your UnitedHealthcare Community Plan. Some over-the -counter medications are covered.
    Prescription drugs: A drug or medication that, by law, can be obtained only by means of a physician's prescription.

  • Primary Care Provider (PCP)

    Your primary care physician is the doctor who takes care of all of your health needs. They are responsible to provide, arrange, and coordinate all aspects of your health care. Often they are the first person you should contact if you need health care. Your PCP is typically a family practitioner, internist, or pediatrician. Having a PCP helps make sure the right medical care is available when you need it.

  • Prosthetics and Orthotics

    These are medical devices ordered by your doctor or other health care provider. Covered items include, but are not limited to, arm, back, and neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part or function.

  • Provider

    A person who is authorized to provide your health care or services. Many kinds of providers participate with UnitedHealthcare Community Plan, including doctors, nurses, behavioral health providers and specialists.

R

  • Referral

    Your PCP can send you to other providers in UnitedHealthcare Community Plan’s network for needed care your PCP cannot provide. This is called a referral.

  • Rehabilitation Services and Devices

    Treatment you get to help you recover from an illness, accident, injury, or major operation.

S

  • Service Area

    A geographic area where a UnitedHealthcare Community Plan is allowed to operate. It is also generally the area where you can get routine (non-emergency) services.

  • Service Authorization

    Approval needed before you can get certain services or drugs. Some network medical services are covered only if your doctor or other network provider gets an authorization from UnitedHealthcare Community Plan.

  • Specialist

    Any doctor who has special training for a specific condition or illness.

U

  • Urgently Needed Care

    Care you get for a non-life threatening sudden illness, injury, or condition that is not an emergency but needs care right away. You can get urgently needed care from out-of-network providers when network providers are unavailable or you cannot get to them.

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Learn More

UnitedHealthcare Community Plan of Virginia - Medicaid (TANF/Medicaid Expansion)

Enrollment Information

The UnitedHealthcare Community Plan of Virginia - Medicaid (TANF/Medicaid Expansion) plan specialists can answer questions and help you enroll.

Call us:
1-844-532-0621 / TTY: 711

8:00 am to 5:00 pm local time, Monday – Friday

Steps to Enroll (Opens in a New Tab)
Get the details

Visit the Cover Virginia site or call 1-855-242-8282 for more information on eligibility and enrollment.

Cover Virginia

Member Information

You have access to our member-only website. Print ID cards, chat with a nurse online, and more.

Member website

Individual & Family ACA Marketplace Plans Disclaimer
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Medical plan coverage offered by: UnitedHealthcare of Arizona, Inc.; Rocky Mountain Health Maintenance Organization Incorporated in CO; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare Insurance Company in AL, KS, LA, MO, and TN; Optimum Choice, Inc. in MD and VA; UnitedHealthcare Community Plan, Inc. in MI; UnitedHealthcare of Mississippi, Inc.; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of Texas, Inc.; and UnitedHealthcare of Oregon, Inc. in WA.  Administrative services provided by United HealthCare Services, Inc. or its affiliates.

1. The benefits described may not be offered in all plans or in all states. Some plans may require copayments, deductibles and/or coinsurance for these benefits. This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, review your plan documents, call or write your insurance agent or the company, whichever is applicable. Plan specifics and benefits vary by coverage area and by plan category. Please review plan details to learn more. This policy has exclusions, limitations, reduction of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company, whichever is applicable. By responding to this offer, you agree that a representative may contact you.

2. Virtual visits conducted by telephone or video chat with a doctor are not an insurance product, health care provider or a health plan. Unless otherwise required, benefits are available only when services are delivered through a Designated Virtual Network Provider. Data rates may apply. Virtual visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times, or in all locations, or for all members, and visit limits may apply. Check your benefit plan to determine if these services are available.

3. Walgreens discount valid until 12/31/23. Discount valid only for in-store purchases of eligible Walgreens brand health and wellness products by current members eligible for the United Healthcare discount program. Discount cannot be used online. For full list of Walgreens brand health and wellness products, please visit www.walgreens.com/Smartsavings.  Offer not available on the following items: photo orders, prescriptions, tobacco, dairy, alcohol, liquor departments, phone/prepaid/gift cards, money orders/transfers, transportation passes, lottery tickets, charitable donations, pseudoephedrine or ephedrine products, newspapers, magazines, stamps, home medical equipment and durable medical equipment products, pharmacy items and services, Prescriptions Savings Club membership fee, and items or services submitted to insurance for reimbursement or where otherwise limited by law. Walgreens reserves the right to discontinue the offer at its discretion.

4 CO specific: $3 copays for Preferred generic drugs or something similar. 

Last Updated: 07.23.2019 at 02:27 PM CDT

Disclaimer Information
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Looking for the federal government’s Medicaid website? Look here at Medicaid.gov.

UnitedHealthcare Dual Complete plans

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

Premium Disclaimer

Dual Special Needs plans have a $0 premium for members with Extra Help (Low Income Subsidy).

Nurse Hotline disclaimer

This service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. The information provided through this service is for informational purposes only. The nurses cannot diagnose problems or recommend treatment and are not a substitute for your provider's care. Your health information is kept confidential in accordance with the law. The service is not an insurance program and may be discontinued at any time. Nurse Hotline not for use in emergencies, for informational purposes only.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan)

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. 

UnitedHealthcare Connected® (Medicare-Medicaid Plan)

UnitedHealthcare Connected® (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.

UnitedHealthcare Connected® for One Care (Medicare-Medicaid Plan)

UnitedHealthcare Connected® for One Care (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and MassHealth (Medicaid) to provide benefits of both programs to enrollees. 

UnitedHealthcare Connected® general benefit disclaimer

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected® Member Services or read the UnitedHealthcare Connected® Member Handbook. 

UnitedHealthcare Senior Care Options (HMO SNP) Plan

UnitedHealthcare Senior Care Options (SCO) is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare and does not have any other comprehensive health Insurance, except Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our Senior Care Options (SCO) program.

Star ratings disclaimer

Every year, Medicare evaluates plans based on a 5-Star rating system. The 5 Star rating applies to plan year 2023.

Important provider information

The Choice is Yours

We will provide you with information to help you make informed choices, such as physicians' and health care professionals' credentials. This information, however, is not an endorsement of a particular physician or health care professional's suitability for your needs.

The providers available through this application may not necessarily reflect the full extent of UnitedHealthcare's network of contracted providers. There may be providers or certain specialties that are not included in this application that are part of our network. If you don't find the provider you are searching for, you may contact the provider directly to verify participation status with UnitedHealthcare's network, or contact Customer Care at the toll-free number shown on your UnitedHealthcare ID card. We also recommend that, prior to seeing any physician, including any specialists, you call the physician's office to verify their participation status and availability.

Some network providers may have been added or removed from our network after this directory was updated. We do not guarantee that each provider is still accepting new members.

Out-of-network/non- contracted providers are under no obligation to treat UnitedHealthcare plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.

American Disabilities Act notice

In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 ("ADA"), UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.

Referrals

Network providers help you and your covered family members get the care needed. Access to specialists may be coordinated by your primary care physician.

Paper directory requests

Paper copies of the network provider directory are available at no cost to members by calling the customer service number on the back of your ID card. Non-members may download and print search results from the online directory.

Inaccurate information

To report incorrect information, email provider_directory_invalid_issues@uhc.com. This email box is for members to report potential inaccuracies for demographic (address, phone, etc.) information in the online or paper directories. Reporting issues via this mail box will result in an outreach to the provider’s office to verify all directory demographic data, which can take approximately 30 days. Individuals can also report potential inaccuracies via phone. UnitedHealthcare Members should call the number on the back of their ID card, and non-UnitedHealthcare members can call 1-888-638-6613 TTY 711, or use your preferred relay service.

Declaration of Disaster or Emergency

If you’re affected by a disaster or emergency declaration by the President or a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, there is certain additional support available to you.

  • Part A, Part B, and supplemental Part C plan benefits are to be provided at specified non- contracted facilities (note that Part A and Part B benefits must be obtained at Medicare certified facilities);
  • Where applicable, requirements for gatekeeper referrals are waived in full;
  • Plan-approved out-of-network cost-sharing to network cost-sharing amounts are temporarily reduced; and
  • The 30-day notification requirement to members is waived, as long as all the changes (such as reduction of cost-sharing and waiving authorization) benefit the member.

If CMS hasn’t provided an end date for the disaster or emergency, plans will resume normal operation 30 days after the initial declaration.