PA Kids Plan Details

Who is the Primary Care Physician (PCP)?
Your child’s Primary Care Physician (PCP) is a doctor.  All eligible children need to have a PCP. Some PCP sites may have medical residents, nurse practitioners and physician assistants who will provide care to your child under the supervision of your PCP. Please check with the PCP’s office. If the PCP stops working with Unison Kids, we will let you know.  You can then pick a new physician for your child.

Remember:

1. For most of your child’s medical care, you must take your child to the PCP.  If you do not, you may have to pay for the care.
2. If your child wants a new PCP, you need to call or write a letter to Unison Kids. 
3. You do not need a referral form from your child’s PCP for dental, vision, OBi/GYP and prenatal care, emergency care, mental health/substance abuse services, chemotherapy, dialysis and radiation.
4. For vision care, you may take your child to any participating vision provider listed in the provider directory.
5. For dental care, you may take your child to any participating dental provider listed in the provider directory.

Getting to Know Your Primary Care Physician
PCPs are doctors. They have their own private practices. They have contracts with Unison Kids. They are not employees of Unison Kids. Unison Kids does not give incentives to (or encourage) doctors or Unison Kids staff when medical decisions are made. All medical decisions made are based on medical necessity only.

When you have picked a PCP for your child, it is important to call the PCP’s office.  Some questions you can ask are:

• when are the office hours?
• what if night or weekend care is needed?
• who takes calls if your office is closed?
• do you need an OK from me to get my child’s records from another office?
• do I need to come to meet the PCP if my child is a new patient?
• is my child due for a check-up?

It is important to know all the staff at the PCP’s office.  You and your child need a PCP that you can know and trust.

 Out-of-Network Services
The Unison Health Plan network includes doctors and hospitals that routinely provide most requested medical services.  If necessary, your PCP can request that you receive services from a provider that is not part of the Unison Health Plan network. If the requested services are available within the Unison Health Plan network of providers, you will be required to use one of these providers. If your PCP’s request for out-of -network services is denied, you may file a grievance or request a DPW Fair Hearing. You may be responsible for payment of services provided by an out-of-network physician, if these services are not prior authorized or if the service is not covered by Unison Health Plan.

Specialist as a PCP
If your child has a very complicated illness or condition, your child may be able to have a specialist assigned as a PCP.  Call the Special Needs Unit (SNU) toll free at 1.877.844.8844. We will tell you if your child qualifies and how to obtain a specialist as a PCP. If you would like a directory of specialists, call Unison Kids Member Services Department at 1.800.414.9025 (TTY 888.616.0021).  Click here to view Unison's online Provider Directory.

How to Obtain Behavioral Health Services for Your Child
Unison Kids has a network of providers who are licensed to practice Behavioral Health to provide benefits to Unison Kids members. Members should call 1.800.414.9025 (TTY 888.616.0021) to obtain behavioral health services.

After-Hours Care
Sometimes your child may need to see the PCP when the office is closed.  If your child needs urgent care, call the PCP’s office.  You will receive directions on how to contact your child’s PCP. There is someone to help 24 hours a day, 7 days a week.

Urgent Care
When your child needs care, treatment, or advice within 24 hours, call your PCP’s office and explain why your child needs urgent care. The PCP will see your child or tell you what to do for your child’s care.

The Right to Privacy
Unison Kids will not give medical information about your child to anyone without your OK, unless the laws require it.  Of course, Unison Kids will share information with the PCP. 

New Services or Procedures
We will evaluate any and all new technologies that are requested by your child’s doctor for your child’s care. Our medical directors, who consider new medical and scientific information, as well as government requirements, review these requests. Any medically necessary treatment, that is not considered to be experimental, will be reviewed and we will notify you and your child’s doctor of the decision.  As new services or procedures are evaluated and approved as newly covered benefits, you will be notified as the parent or guardian of a member of Unison Kids. We will notify you by way of our quarterly newsletter or a special mailing.

Privacy Rules
This notice describes how medical information about Unison Kids members may be used and disclosed, and how their parent or guardian can get access to this information. Please review it carefully. The law says we must help protect the privacy of our Unison Kids members. This handbook explains the rules that Unison Administrative Services and its affiliates use to do that job.  We must follow these rules. We make sure that the providers and everyone else who works with us agree to help protect their privacy and use these rules. We can change our privacy rules. Any changes will apply to all the information we have about our members. If we make changes, we will inform you. Click here for more details.