UNITEDHEALTHCARE HERITAGE ADMINISTRATION GUIDE

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1 UNITEDHEALTHCARE HERITAGE ADMINISTRATION GUIDE

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3 Table of contents Employer and Broker Contacts... 2 Customer care... 3 Eligibility... 5 Enrollment... 7 Billing procedures... 9 Continuation of coverage Health Insurance Portability and Accountability Act (HIPAA) Renewal process Pharmacy benefit program Personal health solutions Notes... 20

4 Employer and Broker Contacts Resource Website/Address Phone Employer and Broker Contacts Benefit & claims questions Billing issues Enrollment additions & terminations Pre-notification/prior authorization of surgery Please Note: Eligibility requests must be received within 31 days of the effective or event date. Additions and eligibility changes can be processed through the Employer eservices portal at Claims: UnitedHealthcare of the River Valley P.O. Box 5230 Kingston, NY Fax, , or electronically submit enrollment forms to: fax: (248) Care24 (Employee Assistance Program) 24-hour NurseLine SM & counselors available Employer assistance / personnel issue resolution Dental Customer Service Dental benefit & claims questions Order dental ID cards or dental directory Life Customer Service Check status of life claims Apply for conversion Vision Customer Service Questions regarding vision benefit Questions regarding vision network Employer Website Assistance navigating through the site Password resets Member Website Assistance navigating through the site Logon issues Optum Bank SM Customer Service HSA questions UnitedHealthcare Benefit Services SM Cobra Administration questions, if elected this service FSA questions, if elected this service Select HRA questions Section 125 questions, if elected IA & IL: AR, GA, NC, SC, TN & VA: OH: , option

5 Customer care How to reach us The UnitedHealthcare Customer Care Center is ready to respond to your employees questions regarding benefits, bills, claim payments, eligibility, health plan identification cards or emergencies. Customer care professionals (CCPs) are available from 8 a.m. to 6 p.m. Eastern time, Monday-Friday. Customer Care Phone Numbers: IA & IL: AR, GA, NC, SC, TN & VA: OH: The UnitedHealthcare website is available to your employees at Subscribe to receive Explanation of Benefits (EOBs) online Search past EOBs Search and view past claims View eligibility and benefits View member handbook and benefit summaries Order health plan ID cards View subscriber agreements or Certificates of Coverage Change personal information such as address and phone number Additional telephone services TDD line for hearing-impaired members at 711 Interactive Voice Response, a self-service telephone system for your employees to order health plan ID cards, or to obtain benefits and eligibility information. Employees calling after hours with non-emergent service issues also have options to use the telephone self-service features, access the UnitedHealthcare website for information. UnitedHealthcare Customer Care will assist your employees who speak a language other than English. We have retained Language Line Services for interpretation needs. To use this service, please call Customer Care and indicate the specific language need. * PRIVACY UPDATE: To protect the privacy of our members, certain information on those 13 and older IS NOT DISPLAYED unless a HIPAA Authorization form is submitted. Members and dependents age 13 and older are required to register separately. 3

6 Privacy/confidentiality guidelines At UnitedHealthcare, we take confidentiality of members personal health information very seriously. Our employees must follow a written confidentiality agreement in addition to the privacy rules under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and state laws. We also meet the privacy expectations of the National Committee for Quality Assurance (NCQA). For details on our privacy practices, you can refer to our Privacy Notice at https://www.uhcrivervalley.com/privacy/. Appeals procedure The majority of member inquiries can be resolved on an informal basis. If a member cannot satisfactorily resolve an issue on an informal basis, he or she can file a formal written appeal. The customer service representative will advise the member of the process to use for resolving a formal complaint. An appeal is a formal complaint about UnitedHealthcare s decision not to pay for, not to provide, or to stop an item or service that a member believes he or she needs. If a member cannot obtain approval for something he or she feels they need, or if the health plan has denied payment of a claim for a service that the member has already received, the member has the right to appeal. The UnitedHealthcare appeal process meets federal government requirements that apply to certain health plans. The formal process has two levels of appeal review available to members. Level I review is an internal review. Level II is an independent review by a board-certified specialist if the appeal is medically reviewable. The turnaround on pre-service decisions for first- and second-level appeals are based on your benefit plan. Members have 180 days from the date of an adverse decision to appeal. Members receive letters with details regarding coverage denials and access to information about how the claims were processed. Filing a claim If one of your employees needs to pay for care because of an emergency or urgent (non-routine) situation when traveling outside of our network, he or she must send us an itemized bill and include the following information: Date of service Description of services obtained Procedure codes for services obtained Diagnosis codes for services obtained Physician/hospital name, address and tax identification number Employees should mail their claim to the address on the reverse side of their health plan identification card. If they are uncertain of the correct address, they may send it to us at: UnitedHealthcare P.O. Box 5230 Kingston, NY Your employees must include their name, member ID, and a daytime telephone number where they can be reached. Payment will be made based on the employee s benefit plan. Employees also have the option to print out and complete an easy-to-use reimbursement form available at under the member section How to File a Claim. This form is optional and can be completed by the employee and his or her health care professional to ensure all information is received and a timely reimbursement occurs. Explanation of Benefits When a claim is submitted by a member or health care professional for services, an Explanation of Benefits (EOB) will be produced and sent to the member. The EOB will include a detailed listing of services that have been processed and what the member s benefit plan has paid and what balance, if any, is payable by the member. An EOB statement will not be generated in some instances, such as drug claims. EOBs are available electronically through the secured, password-protected section of our website, Employees can register for our Member e-services and view their EOBs online. 4 Please consult your Subscriber Agreement, Summary Plan Description, or Certificate of Coverage for specific appeal guidelines.

7 Eligibility Eligibility requirements UnitedHealthcare establishes requirements for eligibility to ensure that claims are paid for eligible members of your group health plan. This section defines who may be covered under your health benefit plan. If you wish to add employees and their dependents to your plan, enrollment information must be completed and submitted to UnitedHealthcare. Eligible employees Permanent full-time eligible employees All full-time active employees who work at least 30 hours per week are eligible to enroll in UnitedHealthcare coverage through your group. NOTE: Can vary by state. Please contact local representative per state ruling. Late enrollee (see special enrollment periods) A late enrollee is a new employee or a newly acquired dependent who did not take coverage at the time of employment, or at the time of initial eligibility. Employees must enroll within 31 days of initial eligibility. For most contracts, late enrollees must wait until the next open enrollment period to apply for coverage, unless an event triggering special enrollment occurs. Changes that affect eligibility Changes in an employee s status sometimes make it necessary for his or her UnitedHealthcare coverage to change. Employee status changes may include termination of employment, election of COBRA, change from family coverage to individual coverage, change from individual to family coverage, change of department number, and change of employee s address. You must notify UnitedHealthcare when any changes in eligibility occur within 31 days of the event. Failure to do so may result in delays in processing claims, as well as incorrect payments. Dependents Marriage If an employee marries, he or she has 31 days from the date of the marriage to apply for or make changes to coverage. If the enrollment information is not received within 31 days, the spouse would be considered a late enrollee. For most contracts, late enrollees must wait until the next open enrollment period to obtain coverage. Newborn child A newborn is covered from the date of birth if UnitedHealthcare is notified within 31 days of the birth. The enrollment information must include the baby s name (last, first, middle initial), birth date, sex, and primary care physician, if required. Coverage may be obtained effective on the newborn s birth date. The appropriate premium difference must then be paid to UnitedHealthcare. Stepchildren, adopted children, children by guardianship Legally adopted children, children who have been placed with the employee for adoption, stepchildren and children who live with the employee and are under the employee s legal guardianship may be covered if they meet all other dependent criteria. A grandchild is not an eligible dependent unless the employee or employee s spouse has been appointed as permanent legal guardian or has legally adopted the grandchild. Legal documentation is required to verify dependency in cases such as adoption or legal guardianship. We will accept the petition filed for adoption or a letter from the agency recognizing placement. The employee should submit enrollment information to UnitedHealthcare requesting coverage no later than 31 days after the date the child is legally placed in the employee s home for the purpose of adoption. Certification of disabled dependents If a child becomes permanently incapable of self-support due to a physical or mental handicap before reaching the maximum age specified in your Subscriber Agreement, Summary Plan Description or Certificate of Coverage, and while enrolled under the parent s coverage, he or she may continue as an eligible dependent under the employee s coverage with appropriate documentation. 5

8 Dependent eligibility UnitedHealthcare understands that choosing a new health benefit plan can be difficult. It s important to find a policy that not only protects you and your employees, but the families involved. The perfect program takes care of all your employees needs at work and at home. That s why we want to make sure that we provide the dependent eligibility coverage that meets your needs. Your UnitedHealthcare Account Representative is here to help you find the plan that s right for your business. If our dependent eligibility guidelines don t match those of your current policies, give us a call. We will make every effort to satisfy your specific needs. Your current policy may cover one or more of the following: Your employee s legal spouse Your employee s unmarried children through the age specified by your state. Your employee s unmarried children who are permanently disabled and rely solely on the employee for support providing the disability occurred while still an eligible dependent Please consult your Subscriber Agreement, Summary Plan Description or Certificate of Coverage for guidelines specific to dependents over the age specified by your state. How we verify a dependent s eligibility Dependents under the age specified by your state, but at least up to the age of 26, are automatically covered under our plan. Most questions about eligibility tend to apply to older dependents. If your state allows coverage for dependents older than 26, we send annual max age termination notifications to both the employer and the subscriber stating that the dependent will be terminated unless we receive employer verification that the dependent still qualifies and should continue to remain on the coverage for another year. A dependent whose coverage was cancelled due to lack of response may be reinstated with no lapse in coverage if he or she is still eligible. Reinstatement of coverage may occur by either: Your employee requests a second copy of the original questionnaire by calling a UnitedHealthcare customer care professional. He or she must complete the second notice and return it to us so that reinstatement occurs with no lapse in coverage. If, according to the questionnaire, the dependent is no longer eligible, coverage comes to an end. OR The employer contacts their Billing and Enrollment primary representative. After the dependent s eligibility has been verified, he or she may request a reinstatement by providing supporting documentation for the reinstatement to UnitedHealthcare. What is the maximum allowable age? We administer dependent eligibility using the maximum allowable age, which is outlined in the Subscriber Agreement, Summary Plan Description or Certificate of Coverage. When a dependent reaches the maximum allowable age, we notify the employee and employer in writing, 60 days in advance of the termination date. Special enrollment periods for medical coverage Certain events constitute special enrollment opportunities when UnitedHealthcare receives enrollment information within 31 days of the event. Examples of these are: Marriage Birth/adoption/placement for adoption Divorce or legal separations Termination of subscriber s or dependent s employment Reduction in working hours causing loss of coverage Cessation of group contribution by employer COBRA coverage is exhausted 6

9 Enrollment An employee may enroll for coverage within the first thirtyone (31) days of becoming eligible for UnitedHealthcare coverage under the terms of the Group Health Contract. To enroll for coverage, the employee must provide all requested enrollment information. If an employee selects family coverage, requested dependent information must be included with the enrollment. Claims will be suspended for any dependent not listed in the group s eligibility file. If a claim is suspended, a letter will be sent to the employee asking that the dependent be verified with the group administrator and added to the eligibility file. Open enrollment period The group administrator has the responsibility to provide an annual open enrollment. During this 31-day enrollment period, eligible employees are entitled to apply for coverage for themselves and eligible dependents. It is preferable to conduct open enrollment days prior to your group s renewal date. Completing enrollment prior to contract renewal provides adequate time to update member records and issue new health plan ID cards. The subscriber must submit requested enrollment information to the employer group administrator during the open enrollment period. If you have any questions regarding the open enrollment process, please contact your UnitedHealthcare Account Representative. Paper enrollment To enroll for coverage, the employee must complete each section of the enrollment application form. Social Security numbers and dates of birth are required for all dependents. Group Administrators should review each employee s application form for accuracy and completeness. Applications should be completed before the employee satisfies the eligibility period established by your group. We require that a completed application is submitted to UnitedHealthcare at initial enrollment, and anytime a member or group makes a change (e.g., name, address, birth date, adding or terminating dependents, canceling family coverage, electing COBRA or state continuation coverage). We can also take nonmaterial changes (e.g., address or telephone number changes), by , telephone, or fax. Send applications to: UnitedHealthcare of the River Valley P.O. Box Salt Lake City, UT Overnight packages can be sent to the following address: UnitedHealthcare of the River Valley 4050 South 500 West Salt Lake City, UT Online eligibility and enrollment services We also make it easier for selected employers to do health plan business online with our interactive features. If you do not submit Electronic Data Interface (EDI) files to UnitedHealthcare, you may be able to take advantage of these features, including submission of online enrollment applications. To learn more about our online features, please contact your UnitedHealthcare Account Representative. Termination of coverage UnitedHealthcare requires notification if an employee has terminated employment or left the service area. This notification must be received within the time frame outlined in the Group Health Contract. The employer may be required by federal or state law to provide continued coverage to terminated employees. Please consult COBRA regulations for this information. Reservists called to active duty If an employer chooses not to continue health care benefits for an employee called to active duty, the employer needs to provide UnitedHealthcare with notice in writing of the date the employee s coverage is to cease. Notification rules and deadlines set forth in the Group Health Contract will apply. While the employee is on active duty, the employer group will need to provide notice in writing to UnitedHealthcare if the employee wishes to have UnitedHealthcare benefits continue for dependents. The spouse or eldest dependent will then be enrolled as the subscriber. Dependents are eligible for this coverage for 18 months after the absence begins, or the period of active-duty service, whichever is shorter. At such time that the employer wishes to resume coverage for the employee, the employer group will need to provide written notice to UnitedHealthcare indicating the date coverage is to resume. No additional waiting period will be imposed by UnitedHealthcare. 7

10 Frequently asked enrollment questions 1 How many hours does an employee have to work to be considered a full-time employee and eligible for full coverage? A minimum of 30 hours. Requirement can vary by state. Please contact local representative per state ruling. 2 Who can answer COBRA questions? COBRA is legislation that applies to the employer rather than to UnitedHealthcare, and we are not able to advise you of your legal obligations under COBRA. However, the federal government provides a hotline that can be of assistance. The COBRA hotline is What happens if a dependent moves from one household to another or from outside a network area without a legal change-of-custody agreement? Absent a legal change-of-custody agreement, moving into a covered member s home or into a network area is not, by itself, a qualifying event. Certain events allow coverage outside of the open enrollment period. 8

11 Billing procedures On the 15th of each month, before payment is due, your group s billing statement will be mailed to you. Payment is due the first of each month for the upcoming coverage month. You should confirm that your monthly billing statement agrees with your payroll records, to reflect accurately the employees who should be enrolled with UnitedHealthcare. When remitting your payment, please indicate your account number (found on your bill) on your check. If you have multiple subgroups, also indicate the amounts you wish us to apply to each subgroup. To further assist you in understanding your bill, we have defined and explained certain commonly used terminology. Balance forward The balance forward approach our billing system uses is similar to a credit card statement. Retroactive changes will be shown on the next statement and will be detailed by subscriber by month. Pay as billed Please pay the Total Amount Due each month. Payment of an amount that differs from the Total Amount Due will result in a balance forward on your next statement. If you notice a discrepancy in your invoice, make a note on the bill, and immediately call or your Billing and Enrollment primary contact shown on the first page of your bill. Your Billing and Enrollment primary contact will work with you to investigate the discrepancy. Timing of adds/deletes/changes Adds, deletes or changes to your membership must be received in our office by the 10th of the month to ensure they will be reflected on your next statement. Premium charges for new members, effective prior to the current month of coverage, and credits for retroactively terminated members will be reported as adjustments on your bill. Due date Payment must be received by the due date shown on your monthly billing statement. Failure to pay your premium may result in termination of the group. Termination of employee s coverage To terminate an employee s coverage, please submit the request to UnitedHealthcare within 31 days of the event. If we do not receive notification of termination by the 10th of the month, that individual will continue to appear on the next billing statement. The appropriate billing adjustment will appear on the adjustment page on the next billing statement, once the termination has been processed. Terminations can be submitted by mail, , fax, website or electronic file. Terminations must be reported within 31 days unless otherwise stated in your contract. It is important that UnitedHealthcare be contacted about employee terminations as soon as the termination occurs or your group may incur additional monthly premium charges. Be sure to retain a copy of any requested terminations for your records. Ways to record a termination: 1 Complete the change section of a UnitedHealthcare application. The signature of the designated representative of the employer is required to process changes or terminations. 2 List all necessary information on company letterhead along with the signature of the designated representative of the employer. For the above options (1 or 2): Mail information to: UnitedHealthcare of the River Valley P.O. Box Salt Lake City, UT Overnight packages can be sent to the following address: UnitedHealthcare of the River Valley 4050 South 500 West Salt Lake City, UT OR Fax information to: Broker Employer Financial Management Group, (248) Always retain a copy of the fax confirmation sheet for your records. 9

12 4 Terminations and changes may be ed to Be sure to include your group number, group name, the name of the person who will be terminating, and the date the termination of coverage should be effective. 5 Website Terminations may be entered through the UnitedHealthcare website for registered employers. Please contact your UnitedHealthcare account representative to learn more about our online features. 6 Electronic Enrollment file Employers that have been set up to submit electronic enrollment to UnitedHealthcare should include terminations on their electronic file. COBRA election First, submit a notification of termination to remove the subscriber from active coverage. Then, if the employee elects COBRA coverage and the first month s COBRA premium has been received from the employee, submit new UnitedHealthcare enrollment to begin the COBRA coverage period. Billing statement Your monthly billing statement consists of the following sections: Account Summary This statement summarizes your current invoice amount along with any payments or adjustments against prior balances due. The total amount due is the amount owed at the time the bill is printed. Any payments received after the billing date shown will be included in your next bill. Please return the detachable coupon with your check and mail to the remit to address located at the bottom of the coupon. Current Subscriber Information This section provides a list of employees covered for the current month, the employee s subscriber ID number (member identification number), billing tier, and premium amount. It will include the total current premium for the month being billed. Please indicate any subscriber termination of coverage dates on this page. Adjustments will appear on the next month s bill. The signature of the designated employer group representative is required to process terminations. For all other changes, including dependent terminations, please contact UnitedHealthcare. Employee Coverage Type This is a summary of the number of employees covered in each tier. The total premium for the current month is summarized by billing tier level. Adjustments This section reflects any retroactive changes made to your account in the form of additions, deletions and billing tier changes that you have submitted. All retroactive changes will be noted on this page of the bill with the month(s) impacted. Any Packaged Savings credits of adjustments will also be reflected in this section. 10

13 Reconciling your billing statement Below are the steps to follow to reconcile your billing statement: 1 Each month when your billing statement is received, verify the information on the top of the first page including your group name, contact person and address. Please call the premium call center (listed on the bill) to have this information updated, if necessary. 2 Review your prior monthly billing statement and verify that the Previous Amount Due has been correctly carried forward to the current month s billing statement and that all payments submitted have been applied toward your group. Check the Adjustment page to confirm that all requested membership changes are reflected. Note: If there are no adjustments needed to your bill, this page will not be printed. Payments posted after the Invoice Date shown on the first page of the bill will be reflected on your next statement. If a payment remitted is not shown, it is likely that changes submitted with your payment are also not reflected. The Adjustment page will indicate the appropriate premium charge or credit when the change is entered. To verify receipt of payment, call the premium call center (listed on the bill). 3 Compare the Current Subscriber Information section to your records to verify correct enrollment of employees. 4 Check the Adjustment page to verify proper adjustment to premium has been made for retroactive membership changes. Note: If there are no adjustments needed to your bill this page will not be printed. 5 Payments are posted by the Broker Employer Financial Management Group area at UnitedHealthcare. All information submitted with the check is forwarded to the Billing and Enrollment primary contact assigned to your group. Changes received by the 10th of the month will appear on your next month s statement along with any premium adjustments necessary. Any premium not paid will continue to appear in the Previous Amount Due on future statements until it is paid or retroactively adjusted. Please pay the Total Amount Due. Frequently asked billing questions 1 The bill has been paid, so why is there an outstanding balance? If payment is not received by the 10th of the month or the Total Amount Due is not paid, an outstanding balance can result. 2 Why is a balance due if payment submitted is reduced by the premium billed for a terminated employee? This would be the difference between the total amount due and the amount you paid. A double credit can occur when an amount other than the Total Amount Due is paid. For example, a double credit occurs if an employee s coverage is terminated and the group deducts the terminated employee s premium from the Total Amount Due, and the following month pays premium based on the Current Charges less Total Adjustments while disregarding the Outstanding Balance due from the prior month. Invoice Total Amount Due includes the credits given for all retroactive adjustments. Since you have already taken the credit the previous month by reducing the payment remitted, paying the Current Charges less Total Adjustments while disregarding the Outstanding Balance due from the prior month results in the credit being taken twice. The billing system gives you credit in the current month for retroactive adjustments. Paying the Total Amount Due each month will prevent this situation from occurring. 3 Member terminations have been requested, so why are changes not reflected on the bill? The employer bill is produced on the 15th of each month prior to the coverage month. Changes must reach UnitedHealthcare before the 10th of each month to appear on the bill. Example: The June bill is produced on May 15. Any changes made to the account must reach UnitedHealthcare before May 10 to be reflected on the June bill. 4 What is meant by a retroactive adjustment? Any credits or charges to your account since your last billing statement was produced other than those for the current month of coverage are retroactive adjustments. For example, a request to terminate coverage for a member was received after the current month s billing statement was created. For each month premium credit is due, a retroactive adjustment will be shown on the Adjustment page of the next month s billing statement. 11

14 5 How are employees added or deleted from the statement? Employees are added when UnitedHealthcare receives enrollment information through established channels. Eligibility is determined according to the terms of your Group Health Contact. Employees are deleted when UnitedHealthcare is notified of a termination. Changes received by the 10th of the month will appear on the next billing statement. 6 When is the premium payment due? Premium payment is due on the first day of each coverage month. Payment should be received by the due date shown on the billing statement. 7 Why is the payment for last month not reflected on this statement? If payment was not received by the 10th of the month, then the payment may not appear until the following month s statement. 8 What course of action should occur if the billing statement is not received by the due date? Please call the premium call center listed on the bill if you have not received your bill by the due date. 9 Where should payment by check be mailed? The remit to address is found in the lower left corner of the payment coupon found on the Account Summary page. To expedite processing of your payment, please use this remit to address. Make checks payable to UnitedHealthcare. We also have the ability to accept your premium by electronic transfer. Please call the premium call center listed on the bill for details. 10 What should be submitted with payment? Indicate your account number on the check stub. If you have multiple subgroups, indicate the amounts you wish us to apply toward each subgroup. If payment is not received by the 10th of the month, then the payment may not appear until the following month s statement. 11 Which amount should be paid? The Total Amount Due is the amount owed at the time the bill is printed. This amount is found on the Account Summary page. 12 How should the Current Subscriber Information page be used? This page allows you to reconcile your bill to your record of covered employees. If you have updates that are not yet reflected on your bill: 1) Please confirm that UnitedHealthcare has been notified of the change, and 2) For any employees no longer covered, list the appropriate termination dates on this page and return with your payment. Only subscriber terminations may be requested using this form. An authorized signature of the employer group is required to process terminations. For all other changes, including dependent terminations, an application is required. 12

15 Continuation of coverage COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA) was passed to provide employees (or former employees), their spouses and their dependents with a temporary extension of group health insurance when coverage is lost due to certain qualifying events. The law applies to employers with 20 or more employees in a group health plan. It requires employers to offer employees and/or their dependents continuation of group health coverage at group rates in certain instances where there is a loss of group insurance coverage. Generally, COBRA coverage must be identical to the coverage provided to current employees. It is the responsibility of the employer to provide the employees and/or their dependents information regarding COBRA coverage. Additional information regarding health benefits under COBRA may be found at: health-plans/cobra.htm. Also, see COBRA Election under Termination of Employee s Coverage. The American Recovery and Reinvestment Act (effective February 17, 2009) provides for a subsidy of up to 65% of the COBRA premium for a nine-month period for employees who were involuntarily terminated from September 1, 2008, through December 31, It also provides a similar subsidy for certain state continuation plans that are comparable to COBRA. Further, ARRA allowed for a second-chance election for persons who were eligible for COBRA from September 1, 2008, through February 16, 2009, but who either did not take COBRA or dropped it before February 16, These persons could elect coverage effective March 1, Some state continuation programs have also established a secondchance election covering the same or similar periods of time. For more information on the impact of ARRA on COBRA and state continuation plans, please refer to the Department of Labor website: dol.gov/cobra. Conversion and continuation 2 State continuation laws apply to most insured employer groups that are not covered by COBRA due to their size. State conversion is available to employees whose coverage under COBRA or state continuation law terminates. If an employee ceases to be covered under an insured group health plan, he or she may be eligible to choose, without evidence of insurability: to continue group coverage according to the terms and conditions of any applicable state laws; and/or to purchase a conversion policy as specified by the member agreement Continuation coverage is a continuation of the active group contract from which the enrollee terminated. Continuation coverage is provided with no break in coverage. Coverage under state continuation laws must be provided for a specific period of time and the length of time may vary depending on the circumstances under which the enrollee lost coverage. With certain exceptions, payment of the total premium is made directly to the employer by the enrollee. Conversion refers to the enrollee s right to convert his or her group coverage to an individual policy without evidence of insurability. This coverage is available whether the person is covered by COBRA or a state continuation law. Benefit levels and premium amounts under the conversion policy may vary from the active group health contract from which the person s coverage terminated. Each state s laws determine what must be covered. The conversion policy may continue indefinitely as long as certain obligations are met, primary of which is payment of premium directly to UnitedHealthcare. Application for a conversion policy must be made within 31 days after the loss of group coverage. The local UnitedHealthcare office can provide information regarding conversion coverage options by request. 2 Check with your UnitedHealthcare representative for state-specific rules. 13

16 Health Insurance Portability and Accountability Act (HIPAA) One purpose of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) is to increase access to health coverage and make coverage more portable when an employee changes jobs. HIPAA amended the Employee Retirement Income Security Act (ERISA) to provide new rights and protections for participants and beneficiaries in group health plans and applies to both fully insured and self-funded groups. The following is a brief summary of HIPAA and its requirements as it relates to your group health plan with UnitedHealthcare. Also visit the Department of Labor website for further information at HIPAA is designed to improve availability of health coverage by: Providing special rights to enroll in plans in certain situations Prohibiting discrimination based on health status Guaranteeing the availability and renewability of health plans for small employers HIPAA is designed to improve portability of health coverage by: Restricting pre-existing condition exclusions and limitations in plans Providing credit for prior coverage to reduce or eliminate pre-existing condition limitations Special enrollment periods HIPAA requires employers to offer special enrollment periods to employees, spouses and dependents who have: Previously opted out and then lost health care coverage; or Exhausted all COBRA coverage; or Experienced termination of other coverage by loss of eligibility (including divorce, separation, death, termination or reduction in hours); or Experienced termination of employer contributions for other coverage (non-cobra). Under these special enrollment procedures, a person must request enrollment, in writing, no later than 31 days after the loss of the other coverage. Individuals who become eligible dependents If a group health plan offers dependent coverage, the plan must offer a special enrollment period for individuals who become eligible dependents through marriage, birth, adoption or placement for adoption. The special opportunity to enroll applies to the employee, spouse and eligible dependents, including the new dependents acquired because of the marriage or newborn/adopted children who triggered the event. Guaranteed availability of health care coverage HIPAA guarantees the opportunity to purchase health care coverage in the individual and small group market without regard to health status. Guaranteed renewability of health care coverage Health plans are required to renew or continue coverage at the option of the employer (for group coverage) or the individual (for individual coverage) except in the case of: Nonpayment of premiums Fraud Change of location by the individual or employer to outside the service area, or Cessation of operations by the group health plan No discrimination based on health status Under HIPAA, group health plans may not establish eligibility rules or charge higher premiums based upon health-related factors. Health factors include: health status, medical condition (including physician and mental illness); claims experience; receipt of health care; medical history; genetic information; evidence of insurability (including conditions arising from an act of domestic violence); disability Group health plans may not refuse to enroll individuals because of participation in activities such as snowmobiling, motorcycling, all-terrain vehicle riding, horseback riding, skiing or other similar activities Group health plans may not establish rules for eligibility that discriminate based upon health-related status Benefits must be uniformly available to all similarly situated individuals 14

17 Renewal process All employers who enter into a contractual agreement for medical coverage with UnitedHealthcare will have rates and coverage for a specified time period, consistent with the terms of the applicable Group Policy Contract. Prior to the end of your contract period, which is usually 12 months, renewal rates will be calculated and delivered to you either by your UnitedHealthcare Account Representative or your Broker. Listed below are common issues that may arise as your renewal date approaches. Renewal rates will usually be developed for your current benefit plan, as well as additional options upon your request. Multiple benefit offerings Small Employer, 2-99 eligible employees Dual option benefit pairings are allowed for groups with 10 or more eligible employees with a limit of two group numbers per employer. Please consult your UnitedHealthcare representative for details. Key Accounts 100+ eligible employees For this segment, each case is case-specific as to how many group numbers are appropriate. Talk with your broker or your UnitedHealthcare representative for specifics. Renewal policies Small Employer: 2-99 eligible employees Renewal rates are generated by UnitedHealthcare 60 days prior to your renewal date and released to you and your UnitedHealthcare Account Representative or to your Broker. Renewal rates may be based upon adjustments for changes in the following factors: base rates, demographic changes, group size, health risk, delivery system, benefits and other factors. The employer must review the accuracy of the Group Health Contract Signature Sheet and sign it if it represents the benefits and rates they wish to purchase. The signed contract must be received by UnitedHealthcare prior to the last day of your current contract term. Failure to submit the signed Group Health Contract Signature Sheet to UnitedHealthcare prior to the contract renewal date may result in termination of coverage. If the Signature Sheet is received on the 1st of the month or later, a $500 reinstatement fee may be included on your next premium bill. UnitedHealthcare is not obligated to accept any reinstatements after the 5th of the renewal month. 15

18 Pharmacy benefit program Your UnitedHealthcare pharmacy benefit provides coverage for the majority of prescription medications approved by the U.S. Food and Drug Administration (FDA). Our goal is to support your enrolled members and their doctors by providing access to a wide variety of medications and helping to make medications more affordable. We offer programs and tools to help members make informed decisions, save money and get the most out of their pharmacy benefit. Pharmacy tools are available online at Our comprehensive online member website lets your employees and family members find answers to their questions and other valuable information, freeing you for other responsibilities. Simply direct them to log on at for the following pharmacy resources and tools: Pharmacy benefit and coverage information Specific copayment amounts for prescription medications Possible lower-cost medication alternatives A list of medications based on a specific medical condition Medication interactions and side effects, etc. Locate a participating retail pharmacy by ZIP code Review your prescription history Using a participating retail pharmacy Members need to understand that they should use a participating retail pharmacy in order to get the most from their pharmacy benefit. Filling prescriptions at pharmacies outside our network will increase their cost. There are more than 65,000 retail pharmacies in our network across the United States, including both chain and independent stores. Encourage your employees and families to find participating retail pharmacies nearby by using Using the mail-order pharmacy Our mail-order pharmacy sends prescription medicines directly to the member by mail a great convenience for medications taken on an ongoing basis, such as those used to treat some chronic conditions such as high blood pressure or diabetes. Additionally, members may save money by using the mail-order pharmacy. Be sure to encourage your employees to visit to get details on how to use OptumRx Mail Service Pharmacy, a list of medications which may be filled as a 90 day supply, and for medicationpricing information. In addition, members can also use the website to: Refill prescriptions Check the status of their order Set up reminders for refills Manage their account Prescription Drug List (PDL) Your UnitedHealthcare pharmacy benefit provides coverage for a comprehensive selection of prescription medications that are listed in the Prescription Drug List. A PDL is a list of FDA-approved brand-name and generic medications. Your Summary Plan Description (SPD) or Certificate of Coverage (COC) show which medications are covered under your plan. Understanding tiers Prescription medications are categorized within three or four tiers, depending on the plan. Each tier is assigned a copayment, the amount members pay when they fill a prescription. Your benefit plan documents specify the copayments, coinsurance and deductibles that are part of your plan. On the Advantage PDL, medications may move to a higher tier up to six times per calendar year, depending on your benefit. Additionally, when a brand-name medication becomes available as a generic, the tier status of the brandname medication and its corresponding generic could change. Since the PDL may change, encourage your employees to periodically visit or call the Customer Care number on their health plan ID card for the most current information. 16

19 Personal health solutions Your employees have a full suite of personal health solutions to help them stay healthy, get healthy or live with unavoidable illness. Across those stages of health, we offer programs and services ranging from online education and health promotion to complex case management and everything in between. Staying healthy UnitedHealth Wellness provides online and offline resources and tools to help members take control of their health and well-being. Getting healthy Care24 registered nurses and master s-level counselors are available by phone 24 hours a day to answer questions and provide decision support for non-urgent medical conditions. Care Management mobilizes the appropriate care resources on behalf of the enrollee. Identifies gaps in care such as missing medications or misunderstanding of care instructions. Living with illness Disease Management identifies chronic diseases and high-risk cases early; helps individuals achieve a greater quality of life and productivity; and minimizes the progression of chronic disease. The longitudinal approach focuses on the whole person, not just one disease. Care delivery management programs UnitedHealthcare helps members lead healthy lives by encouraging preventive care and early treatment. UnitedHealthcare focuses on nine quality initiatives, offering programs to serve employees in the following areas: Childhood and Adolescent Immunizations (Be Wise Immunize) Live Healthy asthma care Breast and Cervical Cancer Screening (Women s Health Initiative) Healthy Pregnancy program Live Healthy heart care (heart failure, cholesterol screening/management and after heart attack) Live Healthy diabetes care Live Healthy Chronic Obstructive Pulmonary Disease Care Preventive Care, including flu shots All programs are managed internally. Be Wise Immunize Childhood immunizations are one of the most important things your employees can do to protect the health of their children. The UnitedHealthcare Be Wise Immunize program sends schedules and other vaccination information to new parents, as well as reminder cards when immunizations are due. Live Healthy asthma care Asthma, a treatable lung disease, affects more than 17 million people in the United States and is the most common chronic health condition that affects children. 3 The UnitedHealthcare asthma program can help your employees manage asthma while helping improve quality of life. The program is designed for plan members from age 5 to 50. Through this program, we educate asthma patients and parents on how to control the condition using guidelines from the National Heart, Lung and Blood Institute. Controlling the disease helps avoid emergency room and hospital treatment for flareups. This may mean fewer missed school days or workdays for patients or their parents. We give providers information on members who may be using asthma medications incorrectly and who have emergency room and inpatient admissions for asthma. Each month newly identified members are sent an educational packet. Members also receive biannual newsletters for asthma education. Women s Health Initiative UnitedHealthcare uses patient education, communication with physicians, and nationally recognized guidelines to promote timely Pap smears and mammograms. Reminders are sent to women who may not have been tested. 3 American Academy of Allergy, Asthma & Immunology 17

20 These tests can offer early detection and prevention of breast and cervical cancers. The average cost for screenings is less than $200, compared to treatment costs that run into the thousands of dollars. 4 Healthy Pregnancy Program UnitedHealthcare offers the Healthy Pregnancy program to your employees. Upon enrolling, a care coordinator will ask questions about the participant s health, lifestyle and other factors that may affect their pregnancy. If the participant is considered a special-needs pregnancy, a maternity nurse will offer to work with them to provide individualized support throughout their pregnancy. We want to give your employees the tools and resources needed to work closely with doctors so that they have a healthy pregnancy and delivery. The maternity nurse works with and complements the care provided by physicians, nurses and hospitals to help ensure participants are informed, healthy and receive the best possible care through their entire journey. 5 Free no cost to you or your employees Pregnancy consultation to identify special needs Online education materials and resources 24-hour toll-free access to experienced maternity nurses Free book: Your Journey Through Pregnancy Free travel tote Live Healthy cardiac programs This program offers useful information about heart failure, cholesterol screening/management and after a heart attack. Members can learn about their symptoms, how these conditions are treated, how the conditions can be prevented, and receiving treatment plan follow-up with their physician/ health care provider. Acute Myocardial Infarction (MI) Heart disease is the leading cause of death in the United States. 6 Widely accepted clinical research indicates that the combination of aspirin, beta-blockers and cholesterol management can significantly reduce the risk of repeat heart attacks. 6 UnitedHealthcare educates and encourages its contracted physicians to include these medications in the continuing care of heart attack patients. Heart failure We promote the use of ACE inhibitors/arbs and beta blocker medications for the management of heart failure. Physicians receive a quarterly list of patients with heart failure who need to be reviewed for the appropriate medications. Members receive education on taking medications and weighing themselves daily. Members also receive biannual newsletters for heart care education. Each month, newly identified members are sent an educational packet. Live Healthy diabetes care Today, patients with diabetes can live healthy, active and productive lives. If a member has diabetes, he or she can learn about how the diabetes program will provide education to help manage the disease. Diabetes affects 17 million people in the United States and accounts for about $98 billion in medical costs and lost productivity each year. 7 Patients with diabetes are at high risk for complications such as blindness, kidney disease, heart attack, stroke and amputation. Preventive care and health education are essential to help avoid these problems. UnitedHealthcare identifies members with diabetes, assesses their risk for complications, follows their treatment and encourages a healthy lifestyle. UnitedHealthcare periodically reminds members of the need for tests and doctor s appointments. This helps contracted physicians treat members with diabetes more effectively and reduces the likelihood of severe complications associated with the condition. Physicians receive a quarterly list of their patients with diabetes who are in need of tests and who have abnormal lab tests that need review. Each month, newly identified members are sent an educational packet. Members also receive biannual newsletters for diabetes education. Live Healthy Chronic Obstructive Pulmonary Disease care According to the Agency for Research Healthcare and Quality, Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung disease that affects 16 million adults in the United States. With COPD, the lungs are damaged and 18 4 American Cancer Society 5 American College of Obstetricians & Gynecologists 6 American Heart Association 7 American Diabetes Association

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