Medical Benefit Highlights for Employees. All Ages and Retirees Under Age 65* Plan Year 2013 September 1, 2012 August 31, 2013

Transcription

1 HealthSelectSM of Texas Medical Benefit Highlights for Employees All Ages and Retirees Under Age 65* Plan Year 2013 September 1, 2012 August 31, * Also applies to return-to-work retirees who choose active employee benefits. If you are retired and over age 65 with Medicare, you have the same benefits, but your coverage is different. Refer to Benefit Highlights for Retirees Age 65 and Over, Plan Year 2013.

2 PROVIDER NETWORK Choose network physicians and hospitals to help you save on health care costs. Welcome HealthSelect SM of Texas is the State s self-funded insurance plan available to employees, retirees and dependents who are eligible to participate in a Texas Employees Group Benefits Program (GBP) health plan. Starting September 1, 2012, HealthSelect medical benefits will be administered by UnitedHealthcare. This means that UnitedHealthcare will provide access to a provider network, process claims and provide customer service. Caremark manages the Prescription Drug Program for HealthSelect. Provider Network With more than 61,900 doctors in Texas, and 684,000 nationwide, our network is one of the largest in the country. How to Find a Physician or Hospital 1. Go to 2. Click on Find a Doctor/Hospital. 3. Click Find a Physician Near You to search for a network provider. 4. Click Find a Facility Near You to search for a network hospital.! Important News for the 2013 Plan Year Effective September 1, 2012: Use your new member ID card that has a new identification and group number Call the new Customer Care Team at UnitedHealthcare toll-free at (866) (TTY 711), 8 a.m. 7 p.m. CT, Monday Friday Create your new online account for access to your member website at myuhc.com/hs Designating PCP (Primary Care Physician) One of the important decisions you make in managing your health is choosing your PCP. A PCP will give you a referral to see a specialist without a referral from your PCP, you will have non-network benefits when you see a specialist, and you will pay more out-of-pocket. When you use network providers and get the necessary referrals, your doctor submits the claims for you and you receive the highest level of benefits. To designate a PCP to take effect on September 1, 2012, simply call our Customer Care Team toll-free at (866) (TTY 711), 8 a.m. 7 p.m. CT, Monday Friday. 2

3 PREVENTIVE CARE Take advantage of your 100% preventive care coverage.* Take Advantage of Preventive Services Covered 100%* Remember to take advantage of your preventive care benefits. Preventive care is care that helps keep you healthy. It can include routine checkups, screenings, immunizations and prenatal care. Certain preventive care services* are usually covered at 100% when you use a network provider. * Under the Affordable Care Act, certain preventive health services are paid at 100% (i.e., at no cost to the participant), conditioned upon physician billing and diagnosis. In some cases, you will still be responsible for payment on some services. Questions about HealthSelect? Visit us online at or call Customer Care toll-free at (866) (TTY 711), 8 a.m. 7 p.m. CT, Monday Friday. Find Quality Care Fast Through the UnitedHealth Premium Designation Program As a HealthSelect member, know that every doctor and facility in our network has been carefully evaluated before we make them available to you. We realize that not all health care is created equal, so we developed the UnitedHealth Premium designation program. It evaluates and recognizes physicians who meet national industry standards for quality care and local market benchmarks for cost-efficiency. Quality Care UnitedHealthcare awards one star to physicians who meet national standards for quality care. Cost-Efficient Care UnitedHealthcare awards a second star to physicians who meet local area benchmarks for cost-efficient use of resources in delivering health care. UnitedHealth Premium Two-Star Physicians Two-star physicians have been recognized for providing quality and cost-efficient care to their patients. They meet or exceed nationally recognized guidelines. 3

4 Plan Year 2013 Benefits At-a-Glance Many preventive services* may be paid at 100%, with no out-of-pocket cost to you when you use network providers. Be sure to get a referral from your PCP when you see a specialist. For services that are diagnostic, meaning they are used to confirm whether you have a certain medical condition, you may pay a copay and/or coinsurance. All covered benefits are paid based on the allowable amount. Benefits At-a-Glance Effective September 1, 2012 Network In-Area Non-Network Out-of-Area** Calendar year (per participant/family) $0 $500/$1,500 $200/$600 Calendar year out-of-pocket coinsurance maximum $2,000 $7,000 $3,000 (per participant and doesn t include copays) Lifetime maximum None None None Primary care physician (PCP) required? Yes No No PCP office visit Specialist office visit Retail health clinic (no PCP referral required) Urgent care clinic (no PCP referral required) You pay: $25 copay for office visit You pay: $40 copay for office visit You pay: $25 copay You pay: $50 copay + 20% 100%, after you pay copay, or 80% if you receive services subject to coinsurance 100%, after you pay copay, or 80% if you receive services subject to coinsurance 60%, 60%, 70%, 70%, Routine physicals, well-woman exams, routine eye exam for children* (one per calendar year for each service) Routine eye exam for adults (one per calendar year, does not include contact lens exam) You pay: nothing* You pay: $40 specialist copay + 20% for lab or radiology done outside office visit 100%* 100%, after you pay copay, or 80% if you receive services subject to coinsurance 60%, 60%, You pay: nothing if services are provided by a network provider 100% 70%, Maternity care Physician charges only; inpatient hospital copay applies You pay either: $25 PCP or $40 specialist copay for first office visit 100%, after you pay copay 60%, 70%, Office surgery and diagnostic procedures Allergy antigens/serum Allergy injections Allergy testing You pay: 20% (office surgery) You pay: nothing (office diagnostics) You pay: nothing (allergy services) 80%, after you pay copay (if applicable), or 100% (for office diagnostics and allergy-related services) 60%, 70%, 4

5 The charts on these two pages include out-of-pocket costs for common services. For detailed information about benefits, limitations and exclusions, refer to the Master Benefit Plan Document under the Publications and Forms tab at on or after September 1, A percentage (%) indicates coinsurance. Benefits At-a-Glance Effective September 1, 2012 Diagnostic low-tech radiology X-rays Mammography Bone density scan Echocardiogram Ultrasound High-tech radiology CT scan MRI Nuclear medicine You will be responsible for the copay and coinsurance per visit. Chiropractic care (benefit maximum of $75 per visit and maximum 30 visits per calendar year, per participant) Inpatient hospital**** (facility charges per admission, $750 copay maximum per admission, $2,250 calendar year inpatient copay max per participant) You pay: nothing (for office-based services) You pay: 20% (for non-office based services) You pay: $100 copay*** + 20% coinsurance You pay $40 specialist copay and/or 20% coinsurance in addition to amounts above the benefit maximum You pay: $150 copay per day up to five days + 20% Network 100% (for office-based radiology), or 80% (for nonoffice based services) 80%, after you pay copay 100% after copay (if applicable), or 80% if you receive services subject to coinsurance 80%, after you pay copay Inpatient physician***** (per admission) You pay: 20% 80% Emergency room In a non-emergency situation, consider less expensive options like a retail health clinic or urgent care clinic. You pay: $150 copay + 20% (waived if admitted) Outpatient day-surgery (facility charges) You pay: $100 copay + 20% 80%, after you pay copay 80%, after you pay copay Outpatient day-surgery (physician charges) You pay: 20% 80% Hearing aids Ambulance services In-Area You pay: $100 copay*** + 40%,, plus amount over benefit maximum You pay: $150 copay per day up to five days + 40%, after you pay You pay: $150 copay + 20% (waived if admitted) You pay: $100 copay + 40%, Non-Network 60%, 60%, after you pay copay and 60%, 60%, and copay 60%, 80%, after you pay copay 60%, and copay 60%, You pay: $100 copay*** + 30%,, plus amount over benefit maximum You pay: $150 copay per day up to five days + 30%, no You pay: $100 copay + 30%, Out-of-Area** Plan pays up to $500 maximum benefit (per ear) for any consecutive three-year period. You pay: 20% 80% You pay: 20%, 80%, * Under the Affordable Care Act, certain preventive and women s health services are paid at 100% (i.e., at no cost to the participant) conditioned upon physician billing and diagnosis. In some cases, you will still be responsible for payment on some services. **Includes Medicare-eligible participants and out-of-state residents. ***No copay if high-tech radiology performed during ER visit or inpatient admission. ****Preauthorization required. *****You may have to pay additional costs if treated by a non-network physician during your hospital stay. 70%, 70%, after you pay copay and 70%, 70%, 70%, 70%, 70%, and copay 70%, 70%, 5

6 SERVICES Get to know new programs and services to help you make smart health care decisions. Personalized Programs Starting September 1, 2012, you will have access to a number of support programs and resources at no additional cost. You can voluntarily enroll in the programs and take advantage of the tools designed to help improve your quality of life. We also have outreach programs where we contact you to see if you would like more information on how to manage a chronic illness or disease. Receive Personalized Guidance Throughout Your Pregnancy The Healthy Pregnancy program helps you through every stage of your pregnancy and delivery. We provide 24-hour access to experienced nurses, access to our online Healthy Pregnancy Owner s Manual and other materials, as well as money-saving coupons. Health Coaching Programs Wellness Coaching gives you access to personal wellness coaches who are certified and specially trained to help you improve your health and well-being. Our Wellness Coaching programs support individuals with the following lifestyle concerns: Diabetes Exercise Nutrition Stress Management Tobacco Cessation Weight Management Heart Health Our wellness coaches are experienced wellness consultants. They can help you set your goals and create a personalized plan to help you meet them. Members get assigned to one wellness coach at the beginning of their program and keep the same coach throughout their program. If you are dealing with more than one issue, you can enroll yourself in multiple programs and receive unlimited telephone coaching or information through the mail. We have multilingual coaching, including Spanish-speaking coaches. To learn more, call toll-free at (877) (after September 1, 2012). 6

7 Get Support for a Chronic Condition A chronic condition may seem overwhelming and at times hard to manage. To help you, we offer many Disease Management programs that provide personalized support for conditions like: Heart Failure Chronic Obstructive Pulmonary Disease (COPD) Coronary Artery Disease (CAD) Diabetes Asthma mynurseline SM : Get Trusted Information When You Need It Registered nurses are available to help you anytime at no extra cost to you. The nurses and master s-level specialists can provide information on: Symptoms and treatment options Doctors and hospitals Health condition management and more Starting September 1, 2012, you can reach mynurseline toll-free at (877) Enjoy discounts that could add up to big savings Enjoy a healthy lifestyle for less with our discounted products and services, including fitness club memberships, weight loss programs, teeth whitening and more. Access our health discount program* online at mynurseline is for informational purposes only. Nurses cannot diagnose problems or recommend specific treatment and are not a substitute for your doctor s care. These services are not an insurance program and may be discontinued at any time. *The health discount program is not insurance. 7

8 ONLINE RESOURCES Check out our online tools, information and resources available for members and pre-enrollment. HealthSelect Websites: Access Before and After You Create Your Online Account Your HealthSelect website is divided into two areas what you can see before and after you create your online account. before you log in A website designed to help State of Texas employees become more familiar with the HealthSelect benefit plan. myuhc.com/hs once you register your account and log in (on September 1 or after) A website designed to help HealthSelect members find their personal benefits information. Find a network doctor in your area. Search by facility or physician. View your and your family s claims history. Find wellness and health education resources. Print a temporary ID card. Review news and updates. Track your medical expenses. See Plan Year 2013 Master Benefit Plan Document (MBPD). Have an online chat with a nurse. 8

9 Online Wellness Services Coming Your Way Starting September 1, 2012, these programs and services are part of your HealthSelect benefit plan at no extra cost to you. Meeting the Needs of Diverse Communities We recognize the importance of diversity in every aspect of our business. That s why we created our multicultural Centers of Excellence: Latino Health Solutions, Generations of Wellness (African American Health) and Asian American Markets. You can find valuable health care information and learn more about medical needs affecting Hispanic families, including an English/Spanish fotonovela that discusses common health conditions. You can find a wealth of useful information about African American health, including recipes, exercise tips and questions to ask your doctor. Health Care Lane Visit texas for information about health and wellness topics. Make sure to check out Wellness Days, a funfilled festival of good health and wellness. You will be entertained and educated on the benefits of your plan. You can find health information and resources, including provider directories, available in Chinese, Korean, Vietnamese and Japanese. From learning more about your own health risks to taking care of sick kids and finding new ways to stay healthy, Source4Women offers complimentary online tools, resources, seminars and events focused on keeping you and your family healthy. Healthy Mind Healthy Body Newsletter Our award-winning Healthy Mind Healthy Body publication provides the latest health news and tips, and allows you to select health topics that meet your personal needs and interests. Topics range from family health and fitness, to diabetes and asthma management. Sign up at on or after September 1, NEW! UHC.TV UHC.TV is our new online television network. It presents educational and entertaining programs about good health and living. Visit today to help you get inspired to grow healthy and live well. 9

10 To learn more about your benefit tools, resources and options: t t t Visit your pre-member website at Call the HealthSelect Customer Care Team at UnitedHealthcare at (866) (TTY 711), 8 a.m. 7 p.m. CT, Monday Friday Starting September 1, 2012, take advantage of your tools and resources by creating your personal myuhc.com/hs online account Administrative services provided by United HealthCare Services, Inc. or their affiliates. The information provided through these programs is for educational purposes only as a part of your health plan and is not a substitute for your doctor s care. Please discuss with your doctor how the information provided is right for you. Your personal health information is kept private in accordance with your plan s privacy policy. mynurseline is for informational purposes only. Nurses cannot diagnose problems or recommend specific treatment and are not a substitute for your doctor s care. These services are not an insurance program and may be discontinued at any time. The Healthy Pregnancy Program follows national practice standards from the Institute for Clinical Systems Improvement. The Healthy Pregnancy Program can not diagnose problems or recommend specific treatment. The information provided is not a substitute for your doctor s care. For a complete description of the UnitedHealth Premium Designation program, including details on the methodology used, geographic availability, program limitations and medical specialties participating, please see myuhc.com : physician_disclaimer_all_markets.pdf Source4Women content and materials are for information purposes only, are not intended to be used for diagnosing problems and/or recommending treatment options, and are not a substitute for your doctor s care. Lists of potential treatment options and/or symptoms may not be all inclusive. Disclosure: The Health Discount Program is administered by HealthAllies, Inc., a discount medical plan organization. The Health Discount Program is NOT insurance. The discount program provides discounts at certain health care providers for medical services. The discount program does not make payments directly to the providers of medical services. The discount program member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount plan organization. HealthAllies, Inc., is located at P.O. Box 10340, Glendale, CA, 91209, , ohacustomercare@optumhealth.com. The health discount program is offered to existing members of certain products underwritten or provided by UnitedHealthcare Insurance Company or its affiliates to provide specific discounts and to encourage participation in wellness programs. Health care professional availability for certain services may be dependent on licensure, scope of practice restrictions or other requirements in the state. UnitedHealthcare does not endorse or guarantee health products/services available through the discount program. This program may not be available in all states or for all groups. Components subject to change. 10

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12 Key Contact Information HealthSelect (UnitedHealthcare)... (866) (TTY 711) 24/7 mynurseline...(877) Healthy Pregnancy...(800) Prescription Drug Program (Caremark)...(888) HealthSelect Website /12