Welcome to Your Health Plan!
Thank you for choosing Health Choice Utah to provide your healthcare. We look forward to serving you and your family.
Member Services Department
The Member Services Department can help members with any questions they may have about the health plan.
If you have a question about your health, Member Services can help you, call us at 1-877-358-8797. Our Member Services Department is open Monday – Friday, 8 a.m. – 6 p.m., except holidays.
The Member Services Department can help you with many questions like these:
- How do I change my doctor?
- What is a covered service?
- What pharmacies can I use?
- Do I currently have coverage?
- What do I do if I move from my service area?
- Can I change to a different plan?
You are responsible for arranging your own transportation to and from your medical appointments. You must try to use your own car, take the bus, or have a family member or friend give you a ride. If you cannot drive yourself, get a ride or if you cannot pay for a ride, you can ask for a Utah Transit Authority (UTA) bus pass by calling your Medicaid Eligibility Worker.
If there is a medical reason you can’t use the bus, you may qualify for services through UTA FlexTrans or PickMeUp Medical Transport. To apply for this service call the Medicaid Information Line at 801-538-6155 or 1-800-662-9651 and ask for the Transportation Unit.
Important Information for Members
Please see the following sections for important information for our members:
Quality Management Performance Measures tell Health Choice Utah how well we are achieving goals set by Medicaid in the areas of preventive health services such as well care visits, dental visits, breast cancer screenings and many more. Medicaid uses Healthcare Effectiveness Data and Information Set (HEDIS®) 2007 specifications to collect and report results of these measures. Developed and maintained by the National Committee for Quality Assurance (NCQA), HEDIS is the most widely used set of performance measures in the managed care industry.
Health Choice Utah continuously checks our Quality Management Performance Measures to identify areas for improvement and apply interventions to help more of our members use preventive services so they can stay healthy!
There may be a time when you are so sick that you cannot make a decision about your own healthcare. You, or a representative chosen by you, have the right to make decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment within the requirements of Federal and State law with respect to advance directives [42 CFR 438.6].
An Advance Directive is a paper that protects your right to refuse healthcare you do not want. It may also tell people about care that you do want.
There are four types of Advance Directives:
Living Will (End of life care)
A Living Will is a piece of paper that tells doctors what types of services you do or do not want if you become very sick and near death and may not be able to make healthcare decisions or give consent for yourself. For example, in your Living Will you might tell doctors if you want to be kept alive with machines or fed through tubes if you cannot eat or drink on your own.
Medical Power of Attorney
A Medical Power of Attorney is a paper that lets you choose a person to make decisions about your healthcare when you cannot do it yourself.
Mental Healthcare Power of Attorney
A Mental Healthcare Power of Attorney names a person to make decisions about your mental healthcare if it is found that you cannot.
Pre-Hospital Medical Directive (Do Not Resuscitate)
A Pre-Hospital Medical Care Directive tells providers if you do not want certain lifesaving emergency care that you would get outside a hospital or in a hospital emergency room. You must complete a special orange form. You can get a free copy of this form by calling the Bureau of Emergency Medical Services at 801-538-6003.
Health Choice Utah respects your right to make decisions about your healthcare and thinks that it is important for you to have one or more of these papers.
You should get help writing your Living Will and Medical Power of Attorney. Ask your doctor for help if you are not sure who to call.
Making Your Advance Directives Legal
For both a Living Will and a Medical Power of Attorney, you must choose someone who will make decisions about your healthcare if you cannot. This person can be a family member or a close friend and is called your agent.
To make an Advance Directive legal, you must:
Sign and date it in front of another person, who also signs it. This person cannot:
- Be related to you by blood, marriage or adoption;
- Have a right to receive any of your personal and private property upon death;
- Be appointed as your agent; or
- Be your healthcare provider.
- Sign and date it in front of a Notary Public. The Notary Public cannot be your agent or any person involved with the paying of your healthcare.
If you are too sick to sign your Medical Power of Attorney, you may have another person sign for you.
After you Complete your Advance Directives
- Keep your original signed papers in a safe place.
- Give copies of the signed papers to your doctor(s), hospital, and anyone else who might become involved in your healthcare. Talk to these people about your wishes concerning your healthcare.
- If you want to change your papers after you have signed them, you must complete new papers. You should make sure you give a copy of the new paper to all the people who already had a copy of the old one.
- Be aware that your directives may not be effective in a medical emergency.
Source of Additional Information and Forms
The following organization provides healthcare directive forms and information:
Aging Services Administrative Office
195 North 1950 West Salt Lake City, UT 84116
Phone: (801) 538-3910
Toll free: 1-877-4aging0 or 1-877-424-4640
Fax: (801) 538-4395
Your local Area Aging and Senior Center may also have forms and information.
If you have complaints about your right to make healthcare decisions, you may contact the Health Choice Utah Member Services Department at 1-877-358-8797.
It is very important for you to decide what treatment you do or do not want.
- Give copies of your Living Will and/or Medical Power of Attorney to your doctor, hospital and any other people involved with your healthcare.
- If you change any part of your Living Will or Medical Power of Attorney, you should make sure you give a copy of the new one to all the people who already had a copy of the old one.
It is the policy of Health Choice Utah to provide members the rights and responsibilities.
It is a prime responsibility of Health Choice Utah to assure that these rights are preserved for its members. In providing health
care and services, the health care provider has the right to expect behavior on the part of members, which is
reasonable and responsible.
Health Choice Utah adheres to the following statement of the basic rights and responsibilities of Health Plan members. A copy of
the Member Rights and Responsibilities will be provided to all members in the Member Handbook and directly to
participating providers in the Provider Manual. Any update to this policy will be communicated to all members and providers.
Member Bill of Rights and Responsibilities
You have the right to make recommendations about the Member Rights and Responsibilities policy to understand
your health problems and participate in developing mutually agreed-upon treatment goals
As a Health Choice Utah member, you have the following rights:
- Have information presented to you in a way that you will understand, including help with language needs,
visual needs, and hearing needs
- Be treated fairly and with respect
- Have your health information kept private
- Receive information on all treatment options
- Make decisions about your health care, including agreeing to treatment
- Take part in decisions about your medical care, including refusing service
- Ask for and receive a copy of your medical record
- Have your medical record corrected, if needed
- Receive medical care regardless of race, color, national origin, sex, sexual orientation, gender identity,
religion, age, or disability
- Obtain information about grievances, appeals, and hearing requests
- Ask for more information about our plan structure and operations
- Get emergency and urgent care 24 hours a day, seven days a week
- Not feel controlled or forced into making medical decisions
- Know how we pay providers
- Create an advance directive that tells doctors what kind of treatment you do and do not want in case you
become too sick to make your own decisions
- Be free from any form of restraint or seclusion used as a means of force, discipline, convenience or
retaliation. This means you cannot be held against your will. You cannot be forced to do something you do
not want to do.
- Use your rights at any time and not be treated badly if you do.
- To be given health care services that are the right kind of services based on your needs.
- To get covered services that are easy to get to and are available to all members. All members include those
who may not speak English very well, or have physical or mental disabilities.
- To get a second opinion at no charge.
- To get the same services offered under the fee for service Medicaid program.
- To get covered services out-of-network if we cannot provide them.
- To make recommendations about Health Choice Utah’s member rights and responsibilities policy.
- Be furnished health care services in accordance with 42 CFR §§ 438.206 through 438.210.
As a Health Choice Utah Member, you have the following responsibilities:
- To follow the rules of your plan
- Read your Member Handbook
- Show your State Medicaid ID card each time you receive medical care
- Cancel doctor appointments 24 hours ahead of time if needed
- Respect the staff and property at your provider’s office
- Use doctors and hospitals in the Health Choice Utah network
- Pay your copayments (co-pay)
- To understand your health problems and be part of making a care plan that both you and your provider
If you have a concern with any part of your healthcare, or would like to complain about Health Choice Utah please call or write Health Choice Utah at 1-877-358-8797, Monday – Friday, 8:00 am – 6:00 pm and a Member Services representative will assist you.
The problem or concern you are calling about will come under one of two areas: Grievances (Complaints) or Appeals which are explained on the following page.
You can file a grievance or an appeal either over the phone or in writing. To file over the phone, please call us at 1-877-358-8797. To file a grievance in writing, please send your letter to:
Health Choice Utah
Attn: Member Grievances
PO Box 45900
Salt Lake City, UT 84145
To file an Appeal in writing, please send your letter to:
Health Choice Utah
Attn: Member Appeals
PO Box 45900
Salt Lake City, UT 84145
Filing a Grievance
A grievance (complaint) is not being satisfied with the way healthcare services were provided to you. Grievances can be about timeliness, appropriateness, access to care, quality of care, staff attitude, rudeness or any other kind of problem you may have had with your healthcare service. A Health Choice Utah Member Services Representative will help you file the grievance and ask you some questions about the concern. Please provide Health Choice Utah with the date the problem happened and any other facts about the problem. Health Choice Utah will look into your grievance. We are here to help you. You will get a letter from us when we receive your grievance and a letter when we are done with the investigation.
If you have received a letter (for example, Notice of Action) regarding a decision to approve or deny a service and you do not understand it, or do not agree with it; please contact the health plan with questions, ask us to re-write the letter, or you may file a grievance. After calling the health plan, if your grievance about the Notice of Action letter is not resolved to your satisfaction, you may complain to the Division of Healthcare Management and Medical Management Unit.
Appeals and Medicaid State Fair Hearing Process
Member Right to Request an Appeal on an Adverse Action
Health Choice Utah may deny services that your doctor asks for or Health Choice Utah may limit or stop care we said you could have. If this happens, you will get a letter from Health Choice Utah called a Notice of Action. The Notice of Action (NOA) will tell you why Health Choice Utah made that decision. We will tell you the law, rule or policy that was used to make their decision and the date that Health Choice Utah made the decision. The Notice of Action will tell you how to ask Health Choice Utah to review the decision. This review is called an Appeal. The Notice of Action will tell you how you can keep getting care during the Appeal process. The Notice of Appeal will also explain that if you lose the Appeal, you will have to pay for the care you got during the Appeals process. Before filing an Appeal, check with your doctor because he or she could have a different plan of care that may be covered.
Requesting an Appeal
You may ask for an Appeal if you get a Notice of Action. You can ask for the Appeal by calling Health Choice Utah Member Services, or by writing a letter to Health Choice Utah. Your Appeal letter has to be sent directly to Health Choice Utah.
You have 90 days from the date of the adverse action to file your Appeal. Health Choice Utah has five (5) work days to send you a letter to let you know that they have received your Appeal. Before you ask Health Choice Utah for an Appeal, and at any time during the Appeal process, you can look at all the paperwork Health Choice Utah used to make the decision. Before Health Choice Utah makes a decision about your Appeal, you can send us more information about your care.
Using a Representative
If you choose to appeal the Notice of Action, you have the right to have help. You can file the Appeal yourself or you can have someone file it for you. If you want someone to help you with your Appeal (like a family member, friend, clergy, or even your doctor) you have to tell the Health Choice Utah Member Appeals Coordinator that you are allowing them to help you.
When Health Choice Utah sends a Notice of Action, we also send a list of agencies that may be able to help you with your Appeal. If you need another list, please call the Health Choice Utah Member Services Department. You cannot have help from someone who will charge you money to represent you.
Your doctor can ask for an Appeal for you. If you want your doctor to ask for your Appeal, you must give your doctor written permission to ask for the Appeal. You or your doctors have 90 days from the date on the Notice of Action to ask Health Choice Utah for the Appeal. If you want to keep getting care during the appeal process, please contact Health Choice Utah. Send your letter or call:
Health Choice Utah
Attn: Member Appeals
PO Box 45900
Salt Lake City, UT 84107
Health Choice Utah will have your file reviewed by someone that had nothing to do with your first Notice of Action that denied, limited or stopped care we said you could have. After Health Choice Utah has looked at your file, we will send you a letter telling you our decision. This letter is called a Notice of Appeal Resolution. The Notice of Appeal Resolution will be sent to you within 30 days after getting your Appeal request (72 hours for an expedited).
Notice of Extension
Health Choice Utah will answer your appeal request as quickly as we can. However, sometimes it is in your best interest that additional time be taken. If Health Choice Utah needs more than 30 days to get all the information needed to fully review to your appeal, we will let you know by sending you a letter. This letter means Health Choice Utah has 14 more days to make a decision. If you need more than 30 days to get all the information you need for your appeal, you can request an extra 14 days to get additional information for your appeal to Health Choice Utah.
You can ask Health Choice Utah to make a decision faster, if waiting 30 days would seriously harm your health, life or your ability to reach, get back, or keep functioning at a maximum level. This is called an Expedited Appeal. Health Choice Utah will let you know if they agree that a fast decision must be made. If Health Choice Utah makes a fast decision, they will try to call you on the telephone. Health Choice Utah will call you in three (3) working days and tell you our Appeal decision. You may still request an Extension of up to 14 days, if it is in your best interest. Health Choice Utah will also send you a letter telling you the decision. This letter is called a Notice of Expedited Appeal Resolution. If Health Choice Utah does not agree that a fast decision has to be made, the Notice of Appeal Resolution will be sent to you in 30 days.
Member’s Right to Request a Medicaid State Fair Hearing on Health Choice Utah’s Appeal Decision
If you do not like the Appeal decision, you can ask for a Medicaid State Fair Hearing. You must ask for the State Fair Hearing in writing. You have 30 days from the date you receive the letter of Notice of Appeal Resolution (or Notice of Expedited Appeal Resolution) to ask for a Medicaid State Fair Hearing. If you want to keep getting care during the hearing process, you must follow the rules listed in the section called Appeals and Grievances in the Member Handbook. Send your letter or call:
Health Choice Utah
Attn: Member Appeals
PO Box 45900
Salt Lake City, UT 84145
After you ask for a State Fair Hearing you will receive a Notice of Hearing from the Utah Department of Workforce services (DWS). The Notice of Hearing will tell you the law, rule, or policy that will be used at the hearing. The Notice of Hearing will tell you where and when the hearing will be held. DWS will also send you information about the hearing. You can either speak for yourself at the hearing or give permission in writing to a lawyer, relative, friend or anyone to speak for you at the hearing. Before, and during the hearing, you (and the person helping you) can look at all the paperwork that will be used at the hearing. You can bring someone to the hearing that knows about your case. You can also bring information about your case to the hearing.
The Medicaid State Fair Hearing
An Administrative Law Judge will hold the Medicaid State Fair Hearing. The Judge will listen to everything that is said at the hearing and read all the documents used in the hearing. After the hearing, the Judge will send a Recommended Decision to the Utah Department of Workforce Services (DWS). DWS will read the Recommended Decision and agree with it, change it or reject it. DWS will send you a letter telling you the decision. This letter is called a Director’s Decision. The Director’s Decision will tell you if you have won or lost at the hearing. DWS will tell you why it made the decision. DWS will also tell you if you have more appeal rights. DWS will send the Director’s Decision about 90 days after your State Fair Hearing. For a fast Appeal you will get the Director’s Decision 3 working days after DWS gets all the information from Health Choice Utah. If you lose the State Fair Hearing, the Director’s Decision will also tell you if you have to pay for the care you got during the State Fair Hearing process.
Receiving Continued Benefits
You can keep getting care during the Appeal and State Fair Hearing process if all the things listed before are true:
- Health Choice Utah stops or limits care if we had said okay to before.
- Your provider ordered the care.
- The length of time of the first okay from Health Choice Utah for your care is not over.
- You ask to keep getting your care.
- You send Health Choice Utah your Appeal before Health Choice Utah stops or limits treatment, or within ten (10) days of the date on the Notice of Action, whichever is later.
- You will continue to get the care until any of the following happens:
- You ask to stop the Appeal or State Fair Hearing.
- You do not ask for continued care and do not ask for a hearing within 10 days from the date that Health Choice Utah sends you the Notice of Appeal Resolution.
- You lost the State Fair Hearing.
- The length of time of the first okay from Health Choice Utah for your care ends.
Please note: You will have to pay for all of the care that you get if you lose the appeal or the State Fair Hearing.
Members are in charge of taking care of their Utah Department of Workforce Services (DWS) ID cards. Using the card in a way that is wrong, such as loaning, selling, or giving it to someone else could result in the loss of eligibility and/or legal action as applied by Federal or State law (42 CFR 455.2). If you witness any misuse of any ID card or any other type of fraud or abuse please contact Member Services, or you can call or write DWS. DWS also has a Member Fraud Hotline you can call at 1-888-ITS NOT OK (1-888-487-6686).
FRAUD is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (42 CFR 455.2).
ABUSE (of member) means provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the DWS program; or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes recipient practices that result in unnecessary cost to the DWS program (42 CFR 455.2).
What if I know of or think there may be Medicaid fraud?
Medicaid PROVIDER Fraud: If you think a Medicaid provider is involved with fraud, please contact:
The Utah Office of Inspector General (OIG)
Toll Free Hotline: 1-855-403-7283
Medicaid CLIENT Fraud: If you think a Medicaid client is involved with fraud, please contact:
Department of Workforce Services Payment Error Prevention Unit
To Report Provider or Client Fraud, Waste or Abuse: oig.utah.gov
If you have questions or concerns about your healthcare, doctors, covered services, or care you are receiving please call Member Services at 1-877-358-8797