How To Understand Your Benefits Plan Information From Unity

Transcription

1 Member Guide Welcome to Unity Health Insurance

2 K E E P T H I S G U I D E F O R F U T U R E R E F E R E N C E Know Your Health Plan The Member Guide is for informational purposes only. It is only a partial, general description of Unity features and benefits. It is not a contract nor any part of one. The complete terms of your health plan are in your Certificate of Coverage. If there are any differences between this Member Guide and your Certificate of Coverage, your Certificate of Coverage is the controlling document. Before seeking any health care under your Unity health plan, please review the following resources very carefully. Together, they will provide the information you need to know to make the most of your health plan benefits: Member Guide Unity Network Provider Directory* Medicare Select Provider Directory* (Medicare Select members only) State of Wisconsin UW Health Provider Directory* State of Wisconsin Community Network Provider Directory* BadgerCare Plus Provider Directory* Certificate of Coverage Schedule of Benefits or Summary of Benefits and Coverage It s Your Choice: Decision and Reference Guides (State of Wisconsin and Local Government Participants only) * Providers are independent contractors and not employees of Unity Health Plans Insurance Corporation. Most of the information in this Member Guide pertains to all Unity members; however, My Choice, POS, Choice Plus, and PPO members will also find information that applies just to them on pages Unity Customer Service If you have any questions about your benefits, send a message to Unity Customer Service through Ask an Expert within MyChart at or call Monday through Friday (7 a.m. to 5 p.m. Central Time) (toll-free) (local) (fax) (hearing impaired) Pharmacy Services: If you are unable to contact Unity during normal business hours, you may call and leave a voic message including your name, subscriber number, telephone number where you can be reached, and the best time (any time day or night) for a customer service representative to return your call. Unity monitors during normal business hours. Unity customer service representatives will gladly assist you in getting answers to your health care coverage questions. If you need language assistance, please see the contact information below. Other Sources of Information Read our quarterly newsletter, UnityNews, for updates to this guide. You can find them at by clicking Members and then Newsletters under Quick Links Visit for information on the following topics: Understanding Your Benefits Plan information Find A Doctor Interactive look-up of Unity providers Health & Wellness Flu Information Preventive Health Managing Your Health Diabetes Tobacco Cessation Asthma Pregnancy and Childbirth Hypertension Behavioral Health Health Appointment Planning Fitness First & More Interactive Tools Health Risk Assessment (HRA) Healthy Recipes Using Your Pharmacy Benefits Understanding Your Pharmacy Benefits Choosing a Pharmacy UW Health Pharmacies Contact Information Important Questions to Ask MyChart View benefit information Check claims status Secure contact with a Unity customer service representative Receive electronic Explanation of Benefits Take a Health Risk Assessment Review Prior Authorizations Plus, if you receive care from UW Health you can view portions of your UW Health medical information 1

3 Contents In recognition of our ability to achieve our service goals, Unity has been awarded a fourth Excellent Accreditation from the National Committee for Quality Assurance (NCQA). See page 34 for more information. Commercial HMO and POS 2 Welcome to Unity Health Insurance 4 Understanding the Concept of Managed Care What is Managed Care? Why Choose Managed Care? 5 Enrollment & Eligibility Information New Member Enrollment Information Your Subscriber/Member Identification Card Changes to Your Enrollment Information Dependent Information Other Insurance Coverage Continuation and Conversion Plans 10 Accessing Primary Care How to Obtain Information about Practitioners and Providers Why Choose a Primary Care Physician (PCP)? How to Choose Your PCP Tips for Selecting a PCP MyChart How to Change Your PCP Making an Appointment for Routine Care After-Hours Clinic Care Accessing Care Away From Home Well-Child Care 13 Accessing Specialty Care Specialty Care Services Procedures and Equipment Requiring Prior Authorization Dental/Oral Surgery, Optometric, Chiropractic, and OB/GYN Behavioral (Mental Health/AODA) Health Care Services Maternity Care Hospital Care 16 Accessing Urgent & Emergency Care Services Urgent Care Services When You Need Urgent Care Emergency Care Services What To Do In Case of An Emergency Follow-up Care for Urgent and Emergency Care Services 18 Pharmacy Benefits & Services Prescription Drug Benefit Prescription Drug Formulary How is the Formulary Developed? Medication Prior Authorization Generic Drugs Why Choose a Generic? Unity s Generic Substitution Policy Vacation Supply of Drugs Step Therapy Program Emergency Drug Supply New Member Drug Supply RX 90 Extended Supply Program Specialty Pharmaceuticals Program Half-Tab Program RX Outcomes Refill Policies 22 Medical & Complex Case Management Guidelines for Care Complex Case Management 23 Claims & Payment Information Claims Submission Out-of-Pocket Expenses 25 Information for POS Members How POS Plans Work My Choice Member Information POS Member Information Choice Plus Member Information 29 Information for PPO Members How the PPO Plan Works PPO Member Information 30 Member Rights & Responsibilities Special Needs Complaints and Grievance Resolution Member Rights Member Responsibilities Confidentiality and Privacy Policies Women s Health and Cancer Rights Act 34 Quality Improvement Programs NCQA Accreditation HEDIS Reporting Member Satisfaction Evaluation of New Medical Technology Ensuring Quality Practitioners and Providers 36 Glossary of Commonly Used Managed Care Terms 1

4 W E L C O M E T O U N I T Y H E A L T H I N S U R A N C E to Unity Health Insurance Welcome to Unity Health Insurance ( Unity ). Our goal is to keep our members healthy while managing the cost of care. Unity provides programs and services to meet your health care needs. We work to provide you with attentive service and quality care through our large network of participating providers. Unity strives to offer convenient access to health care within our service area. Mission Unity is a growing, financially strong organization that provides managed health insurance products and services. We promote quality health care for our members and deliver value to our customers and strategic partners. The cornerstones of this mission are: Choice A variety of benefit options and a broad choice of providers. Access Health care delivered by local, community-based providers with access to state-of-the-art specialty and tertiary care. Value Competitive pricing, administrative efficiency and customer satisfaction. Quality Measurement and improvement of health care processes and outcomes. Vision Unity will be the preferred managed health insurance partner of employers, members, providers and the communities we serve. Customer Service Philosophy Providing excellent customer service is a company-wide goal at Unity. Every employee is dedicated to ensuring members have a high level of satisfaction with their Unity health plan. Unity employees follow a philosophy that helps us provide the high level of service our members deserve. Our Philosophy We strive to: Provide prompt and accurate member services Keep our promises and commitments to our customers Exceed our customers expectations in everything we do 2

5 W E L C O M E T O U N I T Y H E A L T H I N S U R A N C E Health Plan Options Health plan refers to the type of coverage you have. Unity offers a number of health plan options: Health Management Organization (HMO) Plan Members who have this plan agree to obtain all non-emergent health care services through a defined network of doctors, hospitals and other medical professionals. POS Plan This plan allows members flexibility in seeking medical care, with options to stay in plan or go out-of-plan to seek health care services. Refer to page 27. PPO Plan The PPO Plan allows members to access care from providers throughout the United States. See page 29 for more information. HSA-Qualified High Deductible Health Plans (HDHP) High Deductible Health Plans are plans with federally defined deductible limits. By having a HDHP, the subscriber is eligible to open a Health Savings Account (HSA), a tax savings vehicle. Individual Health Insurance Plan Unity offers health plans for individuals and families. Members with coverage under a Unity individual product should contact Unity Customer Service when this Member Guide refers to Your Employer s Benefit Administrator. Medicare Select Plan Unity offers supplemental health insurance plans for individuals who are currently enrolled in Medicare Part A and B. Please visit for more information about these plan types. 3

6 U N D E R S T A N D I N G T H E C O N C E P T O F M A N A G E D C A R E Understanding the Concept of Managed Care More information about Unity s health programs can be found at. What is Managed Care? The philosophy of managed care is to provide members with preventive services in order to keep them healthy. Healthy members are less likely to need more expensive medical care. Managed Care Organizations (MCOs) attempt to reduce costs by creating provider networks through which all members receive their health care. Unity works with its network of providers to ensure members receive timely and appropriate medical care and that unnecessary or untested services are not provided. Unity and its participating providers develop programs to improve member use of preventive health care services. By focusing on prevention of illness and management of chronic disease, members have more control over their health. Why Choose Managed Care? Managed care empowers members to proactively seek preventive health care services. It better suits today s active lifestyle because of these features: Convenient Access Unity s service area covers southwestern and south central Wisconsin. Participating provider clinics are situated to provide you and your family with accessible health care services. Streamlined Administration You are virtually free of hassles and follow-up paperwork when you use an in-network provider and follow any applicable referral requirements. In most cases, your practitioner will submit claims directly to Unity. Coordination of Care Your relationship with your Primary Care Physician (PCP) is important. Your PCP works with you to coordinate all of your health care services. Care Management Doctors and nurses in Unity s care management program, working with your PCP, review treatment plans and requests to coordinate your care. Health Education and Wellness Unity has partnerships with a variety of community providers that offer health education classes and services that can improve your health and well-being. Preventive Health Care Unity has adopted a Preventive Health Care Guideline to help you and your family plan routine visits to your PCPs. This guideline promotes preventive health care services such as age appropriate physical exams, well-child care, cervical cancer screenings, mammograms, and many other services to keep you and your family healthy. 4

7 E N R O L L M E N T & E L I G I B I L I T Y I N F O R M A T I O N Enrollment & Eligibility Information New Member Enrollment Information You will receive your new member materials when you enroll. This includes useful information regarding Unity and your new health plan. Unity encourages you to read your enrollment information thoroughly. Please note that in the future you will receive a new ID card and Schedule of Benefits or Summary of Benefits and Coverage at your group s renewal date only if there are changes to your health insurance benefits. If you misplace an item or have questions, log into MyChart or contact Unity Customer Service. Note: State of Wisconsin and Local Government Participants should refer to the It s Your Choice: Decision and Reference Guides for more information. Your Subscriber/Member Identification Card (ID Card) Your new member information kit includes two ID cards. These cards identify you (the subscriber) and your covered dependents, your group number, a PCP for each family member (if applicable), your provider network and health plan (see page 3). For additional or replacement ID cards, visit and login to MyChart or call Your new ID cards will be sent to you within 5-7 business days. Unity knows that privacy is very important to you which is why your member ID number is a randomly assigned number. There is important information on the front and back of your member ID card. Do not tear it in half you will need the top and bottom portions to present at your clinic or pharmacy when you seek services. Always have your member ID card with you each time you access services from an in-network health care provider or when contacting Unity Customer Service. 5

8 E N R O L L M E N T & E L I G I B I L I T Y I N F O R M A T I O N The front of your Unity member ID card includes the following information: Your Network Use this to search for providers in Find A Doctor: Individual Health Insurance member ID cards will indicate Personal Options in the Your Network section of the HMO ID card. Use Unity Network to search for providers. State of Wisconsin health insurance program member ID cards will indicate State/Local and then either UW Health or Community based on the network chosen in the Your Network section of the HMO ID card. Medicare Select member ID cards will indicate Medicare Select in the Your Network section of the HMO ID card. Use Unity Network to search for providers. HMO Deductible member ID cards will indicate the single/family deductible amounts in the Your Network section of the HMO ID card. Use Unity Network to search for providers. PPO member ID cards will indicate HealthEOS or PHCS in the Your Network section. Subscriber Name Full name of the subscriber. Subscriber No. The subscriber number is a unique number assigned to each individual subscriber. Group No. The group number identifies the subscriber s employer group and is usually the same for all Unity members and their dependents within that employer group. Benefit This lists a summary or code for the benefit coverage for the group, including any office visit and prescription drug copayment amounts. The subscriber s PCP name may also be printed below the benefit information. Member Name Each member/ dependent is listed under member name, along with each individual member s PCP name, clinic name, and telephone number. Person Code Each member/ dependent is identified by a person code. This person code is the last two digits of the member s identification number. The subscriber will always have person code 00. Please include the appropriate person code whenever you contact Unity regarding a specific member. PCP The clinic and Primary Care Physician (PCP) for each member is listed, along with the clinic phone number. Each member shown on a card can have a different PCP. Note: There may be certain circumstances when this information may not be listed. The back of your Unity member ID card also contains important information be sure to read it before using your card. Remember the following: Verify the information on your ID card right away. Notify Unity Customer Service if any changes are needed. It is necessary to present your ID card every time you receive medical care. This includes services at a pharmacy. Please note: State of Wisconsin and Local Government participants should use their Navitus Health Solutions LLC ID card at the pharmacy. BadgerCare Plus members should use their Forward or ForwardHealth card. Notify Unity Customer Service immediately if you lose your ID card or if it is stolen. Do not allow anyone else to use your ID card unless they are insured under your Unity policy. HMO Front Back 6

9 E N R O L L M E N T & E L I G I B I L I T Y I N F O R M A T I O N My Choice My Choice Your Network: Subscriber Name Subscriber No. Group No. Benefit Tier 1 Tier 2 IA Tier Carolina Street Sauk City, WI BENEFIT INFORMATION is available within MyChart at. Simply request an account at unitymychart.com. An activation code will be mailed to your home within 10 days. Once you receive your activation code, follow the instructions to activate your account. URGENT AND EMERGENCY CARE: If you have a serious medical problem where care clearly cannot be delayed, call 911 or obtain care from the nearest medical site. If you are unsure of the urgency of the situation, call your primary care clinic for instructions. If you are admitted to the hospital from the emergency room, you or the hospital staff must notify Customer Service within 3 business days. For after hours care, contact your PCP clinic. Your clinic is required to provide you with instructions for after-hours care. If you use non-participating providers you may incur additional costs and you will be responsible for obtaining Prior Authorizations and Pre-certifications. Member Name Front Person Code Customer Service Send Claims to: (800) Unity Health Insurance TDD (608) PO BOX 610 Sauk City, WI Fax (608) Back PRE-CERTIFICATION: Your participating doctor, hospital staff or provider must call Unity at (800) at least 3 days prior to any non-emergency hospitalization or within 3 business days following an emergency admission. You are responsible for this notification when using a non-participating provider. For members with Unity drug coverage, pharmacies may use: BIN# PCN# / Rx Group# Unity 24-hour pharmacy: (800) This card is for identification purposes only and does not constitute proof of eligibility Unity Health Plans Insurance Corporation POS Point of Service (POS) Your Network: 840 Carolina Street Sauk City, WI BENEFIT INFORMATION is available within MyChart at. Simply request an account at unitymychart.com. An activation code will be mailed to your home. Once you receive your activation code, follow the instructions to activate your account. URGENT AND EMERGENCY CARE: If you have a serious medical problem where care clearly cannot be delayed, call 911 or obtain care from the nearest medical site. If you are unsure of the urgency of the situation, call your primary care clinic for instructions. If you are admitted to the hospital from the emergency room, you or the hospital staff must notify Customer Service within 3 business days. For after hours care, contact your PCP clinic. Your clinic is required to provide you with instructions for after-hours care. If you use out-of-network providers you may incur additional costs and you will be responsible for obtaining Prior Authorizations. PRIOR-AUTHORIZATION: Your participating doctor, hospital staff or provider must call Unity at (800) at least 3 days prior to any non-emergency hospitalization or within 3 business days following an emergency admission. You are responsible for this notification when using a out-of-network provider. Front Customer Service Send Claims to: (800) Unity Health Insurance TDD (608) PO BOX 610 Sauk City, WI Fax (608) For members with Unity drug coverage, pharmacies may use: BIN# PCN# / Rx Group# Unity 24-hour pharmacy: (800) This card is for identification purposes only and does not constitute proof of eligibility Unity Health Plans Insurance Corporation Back 7

10 E N R O L L M E N T & E L I G I B I L I T Y I N F O R M A T I O N PPO Your Network: Subscriber Name Subscriber # Group # Your Network: Subscriber Name Subscriber # Group # Member Name Person Code Member Name Person Code Members: You must notify Unity s Medical Management ( ) within 48 hours of inpatient hospitalizations that were emergent/urgent. Benefit Information is available within MyChart at. Simply request an account at unitymychart.com. An activation code will be mailed to your home within 10 days. Once you receive your activation code, follow the instructions to activate your account. Prior Authorization: You must contact Unity s Medical management for Prior Authorization at least 48 hours before all elective (non-emergent) hospital admissions, skilled nursing facility admissions and inpatient rehabilitation. Prior Authorization Members: is also required You must for transplants, notify Unity s Medical Management genetic testing, home care services, ( ) home IV therapy, within hospice 48 hours care, of inpatient hospitalizations that and purchase of durable medical were equipment emergent/urgent. (DME) in excess of $500 in total. Some specialty injectible Benefit medications Information administered is available by a within MyChart at. professional require Prior Authorization. Simply request Log into an MyChart account or at call unitymychart.com. An activation code Customer Service to determine if will a Prior be mailed Authorization to your home is needed. within 10 days. Once you receive your You are responsible for this notification activation when code, using follow any the provider. instructions to activate your account. Prior Authorization: You must contact Unity s Medical Management for For Provider Network Information: Prior Authorization at least 48 hours before all elective (non-emergent) For care outside of Wisconsin, call hospital PHCS admissions, at (866) skilled nursing facility admissions and inpatient For care in Wisconsin, call MultiPlan rehabilitation. at (888) Prior Authorization is also required for transplants, You may also use Find a Doctor at genetic testing, home care services, home IV therapy, hospice care, and purchase of durable medical equipment (DME) in excess of $500 Customer Service Send Claims to: in total. Some specialty injectible medications administered by a (800) HealthEOS by MultiPlan professional require Prior Authorization. Log into MyChart or call TDD (608) PO BOX 6090 Customer Service to determine if a Prior Authorization is needed. Fax (608) De Pere, WI You are responsible for this notification when using any provider. Fax EDI Payor # (Emdeon): For members with Unity drug coverage, For For Provider Provider pharmacies Network Network may Information: Information: use: BIN# PCN / RX Group# For For care care in Wisconsin, in Wisconsin, call call HealthEOS HealthEOS at (800) at (800) hour pharmacy: (800) For For care care outside outside of Wisconsin, of Wisconsin, call call MultiPlan MultiPlan at (888) at (888) You You may may also also use use Find Find a Doctor a Doctor at at Customer Customer Service Service Send Send Claims Claims to: to: (800) (800) HealthEOS HealthEOS by by MultiPlan MultiPlan TDD TDD (608) (608) PO PO BOX BOX This card is for identification Fax purposes only Fax (608) (608) De De Pere, Pere, WI WI and does not constitute proof of eligibility Fax Fax (262) (262) Unity Health Plans Insurance Corporation EDI EDI Payor Payor # (Emdeon): # (Emdeon): For For members members with with Unity Unity drug drug coverage, coverage, pharmacies pharmacies may may use: use: BIN# BIN# PCN PCN / RX / RX Group# Group# hour 24-hour pharmacy: pharmacy: (800) (800) HealthEOS by MultiPlan T PO BOX 6090 F De Pere, WI u Fax (262) This This card card is for is for identification identification purposes purposes only only and and does does not not constitute constitute proof proof of eligibility of eligibility Unity Unity Health Health Plans Plans Insurance Insurance Corporation Corporation Front Back Choice Plus Choice Plus Your Network: Subscriber Name Subscriber No. Group No. Benefit Level I Level II Level III 840 Carolina Street Sauk City, WI BENEFIT INFORMATION is available within MyChart at. Simply request an account at unitymychart.com. An activation code will be mailed to your home within 10 days. Once you receive your activation code, follow the instructions to activate your account. URGENT AND EMERGENCY CARE: If you have a serious medical problem where care clearly cannot be delayed, call 911 or obtain care from the nearest medical site. If you are unsure of the urgency of the situation, call your primary care clinic for instructions. If you are admitted to the hospital from the emergency room, you or the hospital staff must notify Customer Service within 3 business days. For after hours care, contact your PCP clinic. Your clinic is required to provide you with instructions for after-hours care. If you use non-participating providers you may incur additional costs and you will be responsible for obtaining Prior Authorizations and Pre-certifications. Member Name Front Person Code PRE-CERTIFICATION: Your participating doctor, hospital staff or provider must call Unity at (800) at least 3 days prior to any non-emergency hospitalization or within 3 business days following an emergency admission. You are responsible for this notification when using a non-participating provider. Customer Service Send Claims to: (800) Unity Health Insurance TDD (608) PO BOX 610 Sauk City, WI Fax (608) Back For members with Unity drug coverage, pharmacies may use: BIN# PCN# / Rx Group# Unity 24-hour pharmacy: (800) This card is for identification purposes only and does not constitute proof of eligibility Unity Health Plans Insurance Corporation 8

11 E N R O L L M E N T & E L I G I B I L I T Y I N F O R M A T I O N Changes to Your Enrollment Information You must contact your employer s Benefits Administrator/Human Resources Manager if your enrollment status changes. Notify them of the following changes as soon as possible: Name, address and/or phone number change It is very important you also let Unity know about these changes as quickly as possible. You may do so by logging into MyChart or calling If you update this information at your UW Health clinic, you don t need to contact Unity because it will automatically update in our system. Choosing or changing your PCP See Accessing Primary Care, page 10. Your marriage As the policy subscriber, you must add your spouse to your policy within 31 days following the date of your marriage if you want your spouse insured. Adding a spouse may change your monthly premium. You may be able to add your spouse by logging into MyChart. If not, contact your employer s Benefits Administrator to obtain an enrollment application. If you do not add your spouse within 31 days of marriage, your spouse will be subject to a waiting period. New baby Enroll your newborn under your policy within 31 days following the child s date of birth. Adding a newborn may change your monthly premium. You may be able to add your dependent by logging into MyChart. If not, contact your employer s Benefits Administrator to obtain an enrollment application. Note: A newborn of a dependent (grandchild) may be added only if the dependent parent is under the age of 18. Coverage for the grandchild ends the day the parent turns 18 years of age. Divorce Notify your employer s Benefits Administrator when your divorce is final. You must fill out the necessary paperwork to have your former spouse/stepchildren removed from your policy. Your former spouse/stepchildren may be eligible to continue coverage for a period of time. This is possible through a continuation plan through your employer. You may be able to remove them from your policy by logging into MyChart. If not contact your employer s Benefits Administrator to make these changes. Death of a member Contact your employer s Benefits Administrator to complete the necessary forms. Termination of employment You may be eligible to continue your coverage through your employer group when you leave your job. Contact your former employer s Benefits Administrator for continuation information. Note: State of Wisconsin and Local Government Participants should refer to the It s Your Choice: Decision and Reference Guides for more information about enrollment changes. Dependent Information Adopted children, children placed for adoption, stepchildren Legally adopted children, children placed for adoption, or stepchildren who live with you may be eligible for coverage. Contact your employer s Benefits Administrator for details. Adult children Your adult child is eligible for coverage under your plan until age 26. Contact Unity Customer Service or your employer s Benefits Administrator for further details. Disabled dependents Mentally or physically disabled dependents may be eligible to continue coverage under your policy. Contact your employer s Benefits Administrator or Unity Customer Service for further details. Other Insurance Coverage You must inform Unity if or when you have other health insurance coverage. This information ensures your claims will be submitted and processed correctly. Unity coordinates benefits with your other insurance plan. Always give copies of your health insurance identification cards to the providers you see for health care services. If you have any questions regarding the coordination of benefits, contact Unity Customer Service. To inform us of other coverage, please complete the Other Insurance Questionnaire at by clicking Members and then Other Insurance Questionnaire under Quick Links. Continuation and Conversion Plans If you leave your job, are widowed, experience a divorce or separation, or your dependent child is no longer eligible for coverage through your employer, then you, your spouse or your child may be eligible for continuation benefits. Please talk with your employer about continuation. When you are no longer eligible for your employer s coverage, or when your continuation coverage runs out, you may be able to convert to Unity s conversion product or apply for an individual plan. 9

12 A C C E S S I N G P R I M A R Y C A R E Accessing Primary Care Unity s web site,, has a Find A Doctor feature that allows you to search for providers by their name, city, specialty type or facility. How to Obtain Information About Practitioners and Providers Unity s provider directories list participating PCPs, specialists, chiropractors, pharmacies, hospitals and urgent care facilities by city. Unity Customer Service can assist you in locating a PCP/clinic in your area. Your PCP clinic can assist you with specific questions regarding the board certification status, residency and educational background of a particular provider. Note: PPO members, please visit for more information about the PPO network. Why Choose a Primary Care Physician (PCP)? All Unity members must select or be assigned a participating PCP. A PCP is a physician who manages your health care and helps ensure you receive continuous, quality care in an efficient, cost-effective manner. Your PCP coordinates your medical care through Unity s network of specialty care providers. Note: My Choice members can choose any non-contracted PCP. PPO members do not need to select a PCP. To effectively manage care and help you obtain an optimal level of health, it s beneficial for you to have a close relationship with your PCP. There is also an established working relationship between your physician and Unity. Your PCP should: Know your medical history and coordinate all of your health care needs, including working with medical/surgical specialists and behavioral health (mental health/aoda) practitioners Monitor and coordinate your care if you have a medical condition such as asthma or diabetes Recommend you seek regular preventive health services, such as immunizations, age appropriate physicals and screenings Refer you to participating specialists as needed There are many advantages to having a PCP: The most consistent care is received when one physician has a total history of your health care and can coordinate your care Referrals will be made when needed You will not have to worry about hospital pre-authorization or filing claim forms Out-of-pocket costs can usually be minimized 10

13 A C C E S S I N G P R I M A R Y C A R E How to Choose Your PCP All Unity members must select or be assigned a PCP. Each of your family members has the right to select his/her own participating PCP. The PCP(s) you select for you and your family members may be a: Family Practice Physician (FP) Family Practice with Obstetrics (FP/OB) General Practice Physician (GP) Geriatric Physician (Ger) Internal Medicine Physician (IM) Pediatrician (Peds) OB/GYN Physician (OB/GYN) It is very important you read the introductory section of your provider directory or the help information within Find A Doctor prior to selecting a PCP or PCP clinic. For provider updates, visit Find A Doctor at or contact Unity Customer Service. You should verify the PCP you select is accepting new patients. You can call the clinic directly, visit Find A Doctor at or contact Unity Customer Service to obtain this information. UW Health Welcome Center If you are looking for a PCP at a UW Health clinic and need help selecting one, contact the UW Health Welcome Center at Monday through Friday from 8 a.m. to 5 p.m. You can also send an to [email protected]. In addition to helping you select a PCP, the UW Health Welcome Center will: Work with you to transfer your medical records from your previous health system Gather your medical history Discuss any chronic and/or preventive issues or needs you may have Help you schedule an appointment at the Welcome Center clinic, if needed Assist you with connecting to community resources if needed Note: My Choice members please see page 25. PPO members please see page 29. Tips for Selecting a PCP It is important to take time to select PCPs for your family. PCPs are trained to serve as a person s primary doctor for the long term. Look for a PCP who: Is highly recommended by your friends, family or co-workers Has the training and background that meet your needs Takes steps to help you prevent illness for example, talks to you about quitting smoking Has admitting privileges at the hospital of your choice Encourages you to ask questions Listens to you Explains things clearly so you can understand Treats you with respect MyChart If you have a UW Health primary care physician, sign up for MyChart to view your health information, schedule appointments and communicate with your primary care team. For more information and to sign up, visit unitymychart.com. How to Change Your PCP You can change your PCP by logging into MyChart or calling If you receive care from UW Health, you can also change your PCP at your clinic. The change will be effective on that day unless you request a future date. Note: If you do not notify Unity Customer Service before visiting a new PCP clinic, you may have to pay for the services that you or a family member received. Making an Appointment for Routine Care Contact your PCP clinic when you need non-emergency services or if you have a UW Health PCP you can schedule an appointment through MyChart. It is important each member of your family works with his/her chosen PCP to receive recommended preventive health care, routine screenings and immunizations. When calling your PCP or PCP clinic, keep in mind you may be able to see a Nurse Practitioner (NP) or a Physician s Assistant (PA) instead of waiting for an appointment with your PCP. NPs and PAs are licensed, highly-qualified professional health care providers who work in partnership with physicians. They are available to assist you with physical exams, urgent or problem visits, and follow-up of ongoing health care. Always show your member ID card to the office staff when you arrive at your appointment. After-Hours Clinic Care If you need medical attention after your primary care clinic s normal business hours, call your primary care clinic. Follow the instructions provided by the clinic s messaging system (even when you are outside the service area). In a medical emergency, go to the nearest emergency room. Refer to page 16 for more information on urgent/emergent care. 11

14 A C C E S S I N G P R I M A R Y C A R E Accessing Care Away from Home (Out-of-Area Care) It is important you understand how to obtain health care when you are away from home. We have separated it into two categories: emergency and urgent care, and routine specialty care. The information on pages 16 and 17 will help you understand the process for obtaining emergency and urgent care. Please follow this process whenever you feel you are in need of emergency or urgent care, whether you are near your home, away at school, or on vacation. Routine, follow-up and specialty care should always be obtained when you arrive home. Listed below are some common situations and what you need to know to correctly obtain care: Specialty care as follow-up after an emergency or urgent care admission: All care received as follow-up to an emergency or urgent care admission must be provided by or arranged by your PCP or participating specialist. See page 17 for more information. Vacation: When on vacation you may need to access emergency or urgent care. You should follow the steps on pages 16 and 17. Follow-up appointments after emergency or urgent care and other routine/preventive care must be obtained from your PCP or from a participating specialist. Students away at school: If your child is a covered dependent living away from home while attending school, that child can obtain emergency or urgent care, as needed, where his/her school is located. HMO subscribers who have dependents that are full-time students over age 18 attending post secondary school outside Unity s service area can receive coverage for non-emergency and non-urgent care that is medically necessary and prior authorized. All care must be prior authorized through Unity Medical Management at before care is received in order for services to be covered. For covered services, Unity will pay non-participating providers located outside Unity s service area 50% of usual, customary and reasonable charges, as determined by Unity, up to the maximum benefits stated on the Schedule of Benefits. Note: The enhanced HMO benefit for full-time students is not available to State of Wisconsin and Local Government Participants. Winter away from home: Many Unity members spend several of the winter months in a warmer climate. While you can obtain emergency or urgent care at your winter destination as needed, you must obtain routine and follow-up care from your PCP or a participating specialist. If you are planning extensive travel, you should speak with your PCP to discuss how to obtain necessary medical care while you are away. It is important you are aware of the specialists and facilities that are participating for you and each member of your family so you can correctly obtain routine and follow-up care as necessary. Please refer to Find A Doctor or the front of your provider directory for more information about the providers available to you. Out-ofarea care is limited to usual, customary and reasonable charges. My Choice, POS, Choice Plus and PPO members should see pages to understand how their benefits will pay if they obtain routine, specialty or follow-up care from a provider that is not participating under their Unity plan. Well-Child Care Your child s health and well-being are assessed during well-child exams. In addition, this is a time to discuss disease prevention and health care promotion with your child s PCP. This includes age appropriate immunizations that are a good way to prevent many diseases which can affect young children and adolescents. Children should receive vaccinations according to the recommended schedule in the Preventive Health Care Guideline. The Preventive Health Care Guideline is reviewed at least every two years and can be viewed and printed at. You can also request a paper copy by calling

15 A C C E S S I N G S P E C I A L T Y C A R E Accessing Specialty Care Specialty Care Services Your PCP is responsible for providing primary care services and for coordinating your health care needs. In most cases, your PCP can provide the medical care you need; however, when necessary, your PCP can also refer you to a participating Unity specialist for specialty care. Unity does not require HMO members to receive a referral from their PCP prior to accessing specialty care, however it is beneficial to have a strong working relationship with the PCP. Out-of-plan referral requests will be reviewed only for services that are not available from our participating providers. Services are subject to medical necessity, all benefit maximums, policy limitations and exclusions, and eligibility requirements and are covered up to usual, customary and reasonable charges. For a description of your covered benefits, please refer to your Schedule of Benefits or Summary of Benefits and Coverage and your Certificate of Coverage. Note: State of Wisconsin and Local Government Participants should refer to the It s Your Choice: Decision and Reference Guides for more information. For hospital services, your admitting physician must contact Unity for approval and prior authorization. For elective or planned hospital services, you must use a participating hospital. Contact Unity Customer Service to see if your plan requires Prior Authorization. (If you are a My Choice, POS, Choice Plus, or PPO member, see pages ) Procedures and Equipment Requiring Prior Authorization Some medical procedures and equipment require Prior Authorization. This means your physician must obtain approval from Unity before you can obtain these services. On the next page you will find a list of common procedures requiring Prior Authorization. For a complete list of services that require Prior Authorization, please visit and click Members and then Prior Authorization under Quick Links or contact Unity Customer Service. Note: My Choice, POS and Choice Plus members are responsible for obtaining Prior Authorization for services received from a Tier 2 or out-of-network provider. PPO members, please visit to see what services require Prior Authorization under your plan. Please note: The procedures and equipment requiring prior authorization may not be covered benefits under your health insurance plan. 13

16 A C C E S S I N G S P E C I A L T Y C A R E Members will need Prior Authorization (PA) for the following: Abortions AODA Services Bone Anchored Hearing Aid (BAHA) Behavioral Health Services Biodex Blepharoplasty (Eyes) Cochlear Implants Cosmetic Surgery Treatments Durable Medical Equipment Elective Hospital Admissions Electrolysis Enhanced External Counter Pulsation (EECP) Experimental/Investigational Procedures Genetic Testing Genioplasty (Chin) Home Health Care Hospice Hyperbaric Treatments IDET Procedure Light Therapy [i.e. Levulan Photodynamic or Pulsed Dye Treatments or Actinotherapy (ultraviolet light therapy for acne only; does not require PA for actinic keratoses)] Liposuction Mole Mapping Multifetal Pregnancy Reduction Neuropsych testing (for Behavioral Health only) Osteotomy/Ostoplasty (Mandibular) Panniculectomy (Lipectomy) Penile Implant Prolotherapy Reduction Mammoplasty Revision of Prosthetic Vaginal Graft Rhytidectomy (facelift) Rhinoplasty (nose)/septorhinoplasty Sclerotherapy (Radiofreq ablation, vein stripping, ligation) Skilled Nursing Home Care Treatment of Learning/ Developmental Disabilities TMJ Surgical Treatment Transplants Uvulopalatopharyngoplasty/ Somnoplasty/Uvulectomy LAUP - Laser assisted uvulopalatopharyngoplasty/somnoplasty Warm Water Therapy X Stop Interspinous Implant Pharmacy Prior Authorization is required for some clinic-administered injectable medications. Visit and click Members and then Prior Authorization under Quick Links for the list. Dental/Oral Surgery, Optometric, Chiropractic, and OB/GYN Review your Schedule of Benefits for specific coverage information for these services or contact Unity Customer Service. If you have coverage, simply contact a participating provider to schedule an appointment. Although referrals are not necessary for these services, all benefits are subject to review for medical necessity and to plan limitations and maximums and certain provider limitations. Members covered under a Unity individual insurance plan must review their Certificate of Coverage and Schedule of Benefits or Summary of Benefits and Coverage, as these services may not be covered under their policy. Behavioral (Mental Health/AODA) Health Care Services Unity members can seek services with a participating mental health or alcohol & other drug abuse (AODA) practitioner without a referral from their PCP, although there are certain practitioner limitations for mental health or AODA services. Unity s network includes psychiatrists, psychologists, social workers, and specialty facilities to meet your behavioral health care needs. Unity members in need of behavioral (mental health care/aoda) health care services can call one number for assistance in getting an appointment with a behavioral health practitioner: UW Behavioral Health at (Behavioral health for all members. AODA for members with a PCP outside of Dane County including Black Earth and Cambridge.) or Gateway Recovery at for AODA (For members with a PCP in Dane County only except Black Earth and Cambridge). These phone numbers connect you with staff who will determine the correct type of behavioral health practitioner who can best meet your needs, and will assist you in getting an appointment in a timely manner. Members covered under a Unity individual insurance plan must review their Certificate of Coverage and Schedule of Benefits or Summary of Benefits and Coverage, as these services may not be covered under their policy. 14

17 A C C E S S I N G S P E C I A L T Y C A R E At your first appointment, your mental health or AODA practitioner will evaluate your needs and decide what treatment is necessary. The practitioner will also develop a treatment plan. Your practitioner will get the appropriate authorizations for the recommended treatment. Your Unity plan may have limitations on the amount of coverage available for mental health and AODA services. Review your Schedule of Benefits or Summary of Benefits and Coverage and Certificate of Coverage for a complete list of your benefits. It is important that you keep track of the benefits you have used. Once you reach the benefit maximum, additional benefits are not available until the next benefit year begins. Note: Benefit year differs for each employer group. Confirm the benefit year for your plan by contacting your employer s Benefits Administrator or Unity Customer Service. Members covered under a Unity individual insurance plan must review their Certificate of Coverage and Schedule of Benefits or Summary of Benefits and Coverage, as these services may not be covered under their policy. Maternity Care Good prenatal care is important for you and your baby. Services for prenatal care, delivery and postpartum care are provided while you are a Unity member according to the terms of your policy. PCPs provide a full range of care, including prenatal and postpartum care. Your PCP can confirm your pregnancy and will advise you on the prenatal and postpartum care you need. You may also see a participating OB/GYN specialist, but an authorization may be required for OB/GYN services in specific circumstances. Members covered under a Unity individual insurance plan must review their Certificate of Coverage and Schedule of Benefits or Summary of Benefits and Coverage, as these services may not be covered under their policy. Enroll in 9 Months & More, Unity s prenatal and postpartum program, to receive educational materials and guidance throughout your pregnancy and the delivery of your baby. As part of the program you can sign up for text4baby, a free mobile information service that provides pregnant women and new moms with information to help them care for their health and give their babies the best possible start to life. For more information, visit and click Health & Wellness, Managing Your Health and then Pregnancy/Childbirth. Hospital Care You or a family member may require care and services in a hospital setting for non-emergency (elective/planned) surgery, treatment or tests. For elective or planned hospital services, you must use a hospital that participates in Unity s network. For all elective or planned hospital services, the admitting physician must obtain Prior Authorization from Unity for your hospital admission and stay. Note: If you are a My Choice, POS, Choice Plus, or PPO member, see pages

18 A C C E S S I N G U R G E N T & E M E R G E N C Y C A R E S E R V I C E S Accessing Urgent & Emergency Care Services Visit Health Topics at to check your symptoms to help you determine if you need urgent or emergent care. Urgent Care Services Some medical problems are not life-threatening but do need prompt attention. These include: Most broken bones Sprains Minor cuts Minor burns Non-severe bleeding Ear infections Urgent Care Centers are not emergency rooms nor a replacement for your PCP s office. When You Need Urgent Care 1. Contact your PCP first. Your PCP will tell you how to get appropriate care. Do this even when you are outside the service area. (Unity requires all participating PCPs to have 24-hour call coverage available for you.) 2. If your PCP tells you to seek care at an urgent care facility, show your Unity member ID card to the staff. 3. You must notify Unity Customer Service within three (3) business days following any urgent care treatment from an out-of-network provider. If you visit an Urgent Care Center, you will be responsible for the urgent care copayment or any deductible (refer to your Schedule of Benefits or Summary of Benefits and Coverage). In addition to a copayment or deductible, coverage for services received from an out-of-network Urgent Care Center, may be limited to usual, customary, and reasonable charges. You should work with your PCP if you need any follow-up care. If your PCP tells you to seek services somewhere other than at an urgent care facility, you will need an approved referral before you obtain care. Unity will consider payment for out-of-area urgent care services if you experience a sudden and unexpected illness or injury and all of the following are true: You urgently needed the care, AND You could not have foreseen the need for care prior to leaving the service area, AND You did not specifically leave the service area to obtain care, AND You could not have delayed care until you were able to return to the service area. Your plan will not cover care provided by out-of-area providers if you can safely return to the service area to obtain the care needed. Contact your PCP for all follow-up care. Note: If you are a My Choice, POS, Choice Plus or PPO member, see pages

19 A C C E S S I N G U R G E N T & E M E R G E N C Y C A R E S E R V I C E S Emergency Care Services An emergency medical condition is one that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any one of the following: Serious jeopardy to the person s health or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child. Serious impairment to the person s bodily functions. Serious dysfunction of one or more of the person s body organs or parts. Some examples of emergencies include (but are not limited to): Heart attack Stroke Acute asthmatic attack Acute hemorrhage (bleeding) In these instances, seek emergency services at the nearest emergency facility. What To Do In Case Of An Emergency 1. Go to the nearest hospital or call 911. (Whenever possible, use a participating hospital.) 2. Have someone show your Unity member ID card to the emergency room hospital staff. 3. You must notify Unity within three (3) business days following any emergency treatment from an out-of-network provider. 4. Notify your PCP of your emergency care. Your PCP will help coordinate any necessary follow-up services. If you visit an ER, you will be responsible for the ER copay or deductible (see your Schedule of Benefits or Summary of Benefits and Coverage). You may also have other charges such as lab and X-ray charges, as the result of an ER or urgent care visit. Ambulance transportation may be subject to a copayment or deductible and coinsurance. Depending on your plan, coverage may be limited to usual, customary and reasonable charges. See your Schedule of Benefits or Summary of Benefits and Coverage and Certificate of Coverage. Note: For My Choice members, the coverage for non-contracted providers is limited to the Fee Schedule. Follow-Up Care for Urgent and Emergency Care Services Follow-up care is care you receive after the initial treatment of the urgent or emergency condition. Follow-up care is NOT urgent or emergency care. If an ER physician refers you to a specialist for a follow-up visit, call your PCP before seeing the specialist. Your PCP must provide or arrange for your follow-up care. All follow-up care must be provided within the Unity service area. Out-of-area referrals for HMO members require Prior Authorization from your PCP and approval by Unity. Note: You may have some out-of-pocket expenses if you use an emergency room or an urgent care facility. Refer to your Schedule of Benefits or Summary of Benefits and Coverage and your Certificate of Coverage for a detailed explanation of your benefits or contact Unity Customer Service. (If you are a My Choice, POS, Choice Plus, or PPO member, see pages ) 17

20 P H A R M A C Y B E N E F I T S & S E R V I C E S Pharmacy Benefits & Services Unity s formulary and a list of participating pharmacies are available at. Prescription Drug Benefit The next few pages contain information about Unity s Prescription Drug Benefit. You should also read the following documents, which provide detailed information about Unity s Prescription Drug Benefit: Prescription Drug Benefit brochure Unity s Prescription Drug Formulary Prescription Drug Benefit Rider Some Unity groups and individual plans do not have a prescription drug benefit. Refer to your new member materials or contact Unity Customer Service if you have questions about your drug coverage. Note: Pharmacy information does not apply to members covered under the State of Wisconsin Health Benefits program or BadgerCare Plus members. Prescription Drug Formulary The purpose of a formulary is to promote use of safe effective and cost-effective medications. A formulary is an important tool to help Unity meet its goal of providing coverage for safe and effective medications in an affordable manner. Unity s formulary is made up of formulary medications, a list of non-formulary medications and a list of restricted medications. Formulary medications are the most cost-effective drugs covered by Unity. Non-formulary medications are those that have suitable alternatives on the formulary or those that are considered less effective or less safe for most patients. Restricted medications are those for which you must obtain Prior Authorization from Unity before you can receive coverage. Restricted medications may be formulary or non-formulary. Excluded medications are not listed on the formulary. These are medications that your prescription benefit plan specifically excludes from coverage. Examples of commonly excluded medications include hair loss medications, sexual dysfunction medications, most over-the-counter (OTC) medications and cosmetic medications. Your specific benefit exclusions are listed in the Exclusions section of your Unity Prescription Drug Benefit Rider. 18

21 P H A R M A C Y B E N E F I T S & S E R V I C E S How is the Formulary Developed? Unity s Pharmacy & Therapeutics (P&T) Committee is responsible for creating and maintaining the prescription drug formulary. This committee is made up of physicians and pharmacists who provide care for Unity members in our community. The P&T Committee meets monthly to review medications and determines the formulary status of each medication. They consider a variety of factors such as safety, side effects, drug interactions, how well the drug works, dosing schedule and dose form, appropriate uses and cost-effectiveness. Medication Prior Authorization Some medications on Unity s Prescription Drug Formulary, as denoted with PA, require an approved Prior Authorization prior to coverage through Unity. To see which medications need Prior Authorization, refer to Unity s formulary. To request Prior Authorization, the Medication Prior Authorization Form must be submitted to Unity via fax or mail. It is best that your practitioner submit this form, as clinical information is required for processing. If your practitioner thinks your need for the medication is urgent, he or she should write urgent on the fax. Urgent requests are reviewed first. Requests are reviewed by pharmacists based on criteria set by the P&T Committee. You and your practitioner will receive written notification of the decision. Generally, decisions are made, and notifications sent within two business days of receipt of the request by Unity. If Unity needs more information, it will be requested of your practitioner and the decision and notification may take as long as 15 days depending on how quickly the information is received. For more information, visit and click Members, Using Your Pharmacy Benefits and then Obtaining Prior Authorization under Pharmacy Benefit Links. Generic Drugs A generic drug contains the same active ingredient (the specific chemical ingredient that makes the drug work) as the brand drug. It must have the same dosing and labeling as the brand drug, and must meet the same standards for purity and quality. The United States Food and Drug Administration (FDA) must approve generic drugs as equivalent to the brand before allowing them to be marketed as interchangeable. Because the FDA has determined the generic to be equivalent, your pharmacist can dispense the generic version of your medication without a new prescription from your physician. Why Choose a Generic? Why would you want to choose the generic drug over the brand drug? By choosing a generic, you can save money without losing quality. Generic drugs are not advertised or marketed as much as brand drugs, so generic drugs usually cost less. This allows you to get the generic at a lower copay. Unity s Generic Substitution Policy Unity s Generic Substitution Policy states that when FDA approved equivalent generics are available, coverage of the brand product is only provided with an approved Prior Authorization. If the active ingredient is on the formulary, coverage for the generic is provided at the Tier 1 copay. If the active ingredient is nonformulary, coverage for the generic is provided at the Tier 3 copay. If a Prior Authorization has been approved and the active ingredient is on the formulary, coverage for the brand is provided at the Tier 2 copay. If a Prior Authorization has been approved and the active ingredient is non-formulary, coverage for the brand is provided at the Tier 3 copay. If your prescription is written for the brand drug, with your permission, your pharmacist can dispense the equivalent generic product without a new prescription. The purpose of this policy is to ensure you receive an effective drug at the lowest cost. 19

22 P H A R M A C Y B E N E F I T S & S E R V I C E S Certain drugs on Unity s Prescription Drug Formulary are exempt from the Generic Substitution Policy since even slight differences between brands or brands and generics could cause differences in the effect of the drug. These medications are sometimes called Narrow Therapeutic Index medications. To see which medications are exempt, refer to Unity s Prescription Drug Formulary. Drugs denoted with NTI are exempt. Vacation Supply of Drugs Members who are planning to travel should ensure they have adequate supplies of their medications while they are traveling. There are three ways to make sure you have what you need: 1. Call Unity Pharmacy Services at to receive approval for coverage for an extra 30-day supply to take with you. (Applicable copays apply.) 2. Make arrangements with your local pharmacy to send your medications to wherever you ll be staying when they are needed. 3. Go to a Unity-participating pharmacy located where you re staying. Unity has a national network of participating pharmacies from which you can receive medications. For a list of pharmacies, visit and select Members, and then Find A Pharmacy under Quick Links. Step Therapy Program Certain medical conditions can be treated using a variety of medications. In some cases, there is a very large difference in cost among the medications, but a very small difference in the way the medications work. Unity s Step Therapy Program is approved by the P&T Committee and requires a member to try the more cost-effective medications before receiving coverage for (or stepping up to ) the more expensive medications. Many members find the first medication very effective and never need to step up. For more information about Unity s Step Therapy Program, visit and select Members, Using Your Pharmacy Benefits and then Step Therapy under Pharmacy Benefit Links. Emergency Drug Supply If you have an urgent need for medication that requires a Prior Authorization and you need the medication before the Prior Authorization can be reviewed, your pharmacy can contact Unity Pharmacy Services at to receive coverage for a five-day emergency supply of that medication. For more information on the emergency drug supply, visit and select Members, Using Your Pharmacy Benefits and then Emergency Drug Supply under Pharmacy Benefit Links. New Member Drug Supply Members new to Unity may be taking medications that require Prior Authorization for coverage. New members may also be in the process of identifying and making appointments with new primary care physicians. To assist in making this transition, Unity provides new members with coverage for up to 90 days (in 30 day increments at the usual copayment) of their current medications that usually require Prior Authorization. When the 90 days is complete, a Prior Authorization is required before the member can receive additional coverage. To request a New Member Override, you or your pharmacy can contact Unity Pharmacy Services at within the first 90 days of being a Unity member. 20

23 P H A R M A C Y B E N E F I T S & S E R V I C E S RX 90 Extended Supply Program Unity s RX 90 Extended Supply Program provides coverage for a 90-day supply of a qualified medication taken long-term without dosage changes for two copayments instead of three. Members can receive the medication either by mail or in person at a selected pharmacy. To qualify, a program pharmacist must verify with your practitioner that your medication is needed on a long-term basis and at a stable dosage regimen. For more information about the program and who to contact to see if you qualify, visit and select Members, Using Your Pharmacy Benefits and then RX 90 Extended Supply Program under Pharmacy Benefit Links. Specialty Pharmaceuticals Program Specialty pharmaceuticals are a group of self-administered medications used on a chronic basis to treat various conditions. Medications denoted by SP on the formulary are required to be obtained from a pharmacy participating in the Unity Specialty Pharmaceuticals Program for coverage through Unity. For more information about the Specialty Pharmaceuticals Program, visit and select Members, Using Your Pharmacy Benefits and then Specialty Pharmaceuticals Program under Pharmacy Benefit Links. Half-Tab Program Unity s Half-Tab Program is designed to help maintain the affordability of prescription drug benefits while providing coverage for the same high quality medications. The program is completely voluntary and it decreases your copayment by half for certain medications when you split a higher strength tablet in half and take half a tablet daily for the same total daily dosage. Medications denoted by H on the formulary are eligible for the Half-Tab Program. For more information about Unity s Half-Tab Program, visit and select Members, Using Your Pharmacy Benefits and then Half-Tab Program under Pharmacy Benefit Links. RX Outcomes Unity s RX Outcomes benefit provides lower cost access to medications that improve medical results the most, saving you money and helping reduce medical costs. For more information, visit and select Members, Using Your Pharmacy Benefits and then RX Outcomes under Pharmacy Benefit Links. Refill Policies Time to Refill For maintenance medications, Unity requires that 75% of the supply of a medication be used before providing coverage for refills. This means that approximately three weeks must elapse after receiving a four-week supply of medications before you are eligible for coverage of a refill. Refill Too Soon If you need a refill of your medication earlier than usual because your practitioner has modified your dosage, your pharmacy may contact Unity Pharmacy Services at for a Refill Too Soon authorization. For more information about your pharmacy benefits and services including important phone numbers to call, visit and select Members and then Using Your Pharmacy Benefits. 21

24 M E D I C A L & C O M P L E X C A S E M A N A G E M E N T Medical & Complex Case Management Guidelines for Care Unity carefully reviews treatment plans and requests submitted by participating practitioners. This process of medical management sometimes called care management or utilization management is conducted by nurses with the support of physicians. This process also helps ensure expensive services are not overused so health care can remain affordable for everyone. Medical management staff work with your PCP to coordinate your care at three stages: Pre-service review before you receive care or services Concurrent review while care or services are being provided Post-service review after care or services have been provided The care recommended for you by your health care practitioner is compared to your member certificate and/or nationally, scientifically based care criteria. These criteria, developed and refined with input from hundreds of physicians and applied in the cases of thousands of patients, involve review of your condition and symptoms to identify the treatment strategies which are most likely to be beneficial to you. The criteria are further subjected to a thorough annual review by physicians and other medical experts in our own community and are modified as necessary to meet local needs. The provisions of your member certificate and the guideline-based system eliminates reviewer subjectivity, guides decisions about clinical appropriateness that support cost-effective, appropriate level of care decisions. The medical management teams can provide you with copies of the care guidelines and specific criteria used to make our decisions upon request. You may request the guideline criteria by contacting the appropriate medical management team. UW Health (UWMF) Medical Management for medical coverage determinations UW Behavioral Health for behavioral health coverage determinations Gateway Recovery for substance abuse coverage determinations The guideline/criteria show how health care providers across the United States are practicing. They are supported by evidence-based clinical care and are not considered financiallyderived utilization controls. Unity monitors the utilization management (UM) decision- making processes to ensure appropriate utilization and prevent inappropriate denials. In addition, Unity s Utilization Management/Technology Assessment Committee (UM/TAC) consists of plan physicians who oversee UM activities. Unity works with participating physicians and medical management staff to ensure decisions regarding treatment are based only on appropriateness of care and service. Unity does not reward practitioners or other individuals involved in the medical management process for issuing denials of coverage or service. Unity does not offer financial incentives for medical management decision makers to encourage decisions that result in underutilization. Medical management staff and the behavioral health groups are available at least eight hours a day during normal business hours to receive and return calls regarding medical management issues. After normal business hours, calls are answered by an answering machine or service and are returned the next business day. Staff members identify themselves by name, title and organization when receiving or returning calls relating to medical management issues. A toll-free number is also available to accept and address medical management concerns. The numbers to call are: UW Medical Foundation (Local) (Toll-free) UW Behavioral Health (Local) (Toll-free) Gateway Recovery (Local) Unity (Local) (Toll-free) Complex Case Management Unity will coordinate services for members with a serious, complicated medical problem or a diagnosis that requires an extensive use of resources. Complex case management is a process in which nurses work with both you and your doctor to coordinate, monitor and evaluate your options. We will also help navigate the system for the services available to best meet your health care needs. Our goal is to help you regain optimum health or improve your health to the greatest degree possible. A process to assess the needs of each member includes a health status assessment, clinical history, caregiver resources and benefits. The case manager will then set an individualized care management plan with goals. Progress will be assessed at various points by the case manager and your practitioner. Unity's case management staff may become involved with you, such as notification by a facility or practitioner of a critical event or a diagnosis for a complicated problem that you may experience. Your doctor may also refer you to our care team or you may contact us at

25 C L A I M S & P A Y M E N T I N F O R M A T I O N Claims & Payment Information Claims Submission Sometimes a participating provider may bill you by mistake...even though we ask them to bill us directly. If you believe you have received a bill in error, please contact Unity Customer Service. It may be necessary for you to submit a claim if you receive services from an out-of-network provider. To do this, you must complete the member claim form which can be found by going to and selecting Members and then Member Claim Form found under Quick Links. Send Unity this form along with an itemized bill with a receipt to show payment within 90 days from the date the services were provided. The itemized bill should include: Member Name Date of Birth Date of Service Diagnosis Codes (if applicable) Procedure Codes (if applicable) Billing Amount Provider Name and Address (If you are a PPO member, see page 29.) Unity recognizes that circumstances beyond your control may not allow you to submit the claim within 90 days. If this is the case, we will process your claim if you submit it within the next 12 months. If you receive medical care in another country, you must provide an English translation of the claim and include supporting documentation so that we can process the claim. Keep copies of this information and send the originals to us. If you receive a statement from a provider indicating the provider has filed a claim with Unity, you do not have to do anything. Unity will process the claim. Keep the statement for your records. Claims for reimbursement of prescription medicines should include the information previously listed (except diagnosis and procedure codes), as well as the following information: Name of the medication Quantity of the medication ID number of the medication (NDC) ID number of the pharmacy (NABP) ID number of the practitioner prescribing the medication (DEA) You can usually find this information on the receipt you received from the pharmacy. You can also fill out a Direct Member Reimbursement Prescription Claim Form by going to and clicking Members, Using Your Pharmacy Benefits and then Prescription Claim Form under Pharmacy Benefit Links. Unity generally processes claims within 30 days after the provider has submitted complete information. For pharmacy-related claims or questions, call our pharmacy services representatives directly at They are available 24 hours/day, seven days/week. 23

26 C L A I M S & P A Y M E N T I N F O R M A T I O N Out-of-Pocket Expenses You may have to pay some costs when you receive covered medical or pharmacy services. These costs are called out-of-pocket expenses. They include: Copayment ( Copay ) A fixed dollar amount you are responsible for paying to the practitioner, facility or pharmacy when you receive medical services. Coinsurance The percentage of the fee for a service for which you are responsible, as listed in your Schedule of Benefits or Summary of Benefits and Coverage. Coinsurance amounts apply after any deductible is satisfied. Deductible A fixed amount of money a member or family must pay before Unity will make a payment toward a covered service. Usual, Customary, and Reasonable The amount covered by Unity based upon the customary charges of all providers within a given geographic area for the same or similar service. Fee Schedule The maximum amount of money Unity will reimburse non-contracted PCPs, specialists and hospitals for covered services rendered to My Choice members. You are responsible to pay for services excluded under your Unity insurance plan. Review your Certificate of Coverage for a description of excluded services, or call Unity Customer Service. State of Wisconsin and Local Government Participants should refer to the It s Your Choice: Decision and Reference Guides for a list of excluded services. If you have out-of-pocket expenses, Unity provides you with an Explanation of Benefits (EOB) that explains the amount that is your responsibility to pay to the provider. An EOB is not a bill the provider who performed the service will send you a bill. For confidentiality purposes, Unity mails an EOB to the family member who received the service (i.e., your child will receive an EOB directly in his/her name). EOBs will not be mailed when the out-of-pocket expense is only a copayment. If you receive EOBs electronically, you will receive EOBs for your dependents under 12. To receive your EOBs electronically, simply request a MyChart account at unitymychart.com. All members 18 and older should have their own account. You can send a message to Unity Customer Service through Ask an Expert within MyChart at to obtain a copy of a claim profile for any family member. This profile includes: Date(s) of service Provider s name Amount of claim(s) Amount(s) paid by Unity Any copay/deductible amounts for which the member is responsible Profiles will be sent in separate envelopes addressed to the particular person whose profile is requested. Note: If you are a My Choice, POS, Choice Plus, or PPO member, see pages

27 I N F O R M A T I O N F O R P O S M E M B E R S Information for POS Members How Point-of-Service (POS) Plans Work As a POS member, you can choose your level of flexibility and payment each time you seek medical care. You have a choice as to whether you access health care services within or outside the Unity network of providers. When you receive care from a provider not listed in Unity s Network you are responsible for submitting a claim form to Unity within 90 days from the date the services were received. We will still process your claim if you submit it within the next 12 months. My Choice Member Information My Choice is a two-tier, open access POS plan that does not require you to use in-network providers; however, you will receive the highest level of coverage (Tier 1), by accessing care from contracted practitioners and providers listed in the Unity Network Provider Directory or Find A Doctor at. To obtain Tier 1 benefit coverage for specialty care: 25

28 I N F O R M A T I O N F O R P O S M E M B E R S Tier 1 At this tier, you receive the highest level of coverage. To obtain these benefits, you need to choose a PCP and obtain specialty care through physicians contracted with Unity. You have the least amount of out-of-pocket expenses at this tier. With the My Choice product, you do not have to obtain referrals from your PCP to receive specialty care when you receive it from contracted providers. Tier 2 This tier allows you to see any doctor. You obtain a higher level of coverage with this tier if you access health care through a primary care physician (PCP) inside the plan s service area. You are also free to choose a non-contracted PCP, specialists and hospitals inside and outside the plan s service area. My Choice members must select or be assigned a contracted or non-contracted PCP. Although you are not required to seek services with or through your PCP, your PCP can ensure you receive coordinated health care. Your health care services are subject to medical necessity, all benefit maximums, policy limitations and exclusions and eligibility requirements. Coverage is limited to the fee schedule. More information about the fee schedule can be found on Unity s web site under Members. The My Choice plan does not require any referrals but Prior Authorization may be needed for certain services. See page 14 or visit and click Members and then Prior Authorization under Quick Links. Covered services received from a non-contracted PCP or a noncontracted specialist will always be payable under your Tier 2 benefit and subject to the My Choice Fee Schedule. Refer to your Schedule of Benefits, Prescription Drug Formulary, Certificate of Coverage, and the fee schedule to determine your out-ofpocket expenses when receiving medical and pharmacy care. 26

29 I N F O R M A T I O N F O R P O S M E M B E R S POS Member Information The POS plan is a Point-of-Service product. This means the amount of coverage you receive depends on the point at which you access care. You will receive the highest level of coverage (In-Plan level) by utilizing in-network practitioners and providers. Participating for POS members refers to the practitioners and providers available to you based on your Find A Doctor section online at with the exception of certain specialty clinics if you have a PCP in Dane County (excluding the communities of Black Earth and Cambridge). You have two ways to access care: In-Plan You seek care from your participating PCP or from any specialist available to you based on your Find A Doctor section online at with the exception of certain specialty clinics if you have a PCP in Dane County (excluding the communities of Black Earth and Cambridge). Out-of-Plan You receive services from a provider who is not part of the Unity provider network or from certain specialty clinics if you have a PCP in Dane County (excluding the communities of Black Earth and Cambridge). POS members must select or be assigned an in-network Unity PCP. However, you are not required to seek services with or through your PCP, although your PCP can ensure you receive coordinated health care. Your health care services are subject to medical necessity, all benefit maximums, policy limitations and exclusions and eligibility requirements. If you receive services from out-ofnetwork providers, coverage may be limited to usual, customary and reasonable charges. You must notify Unity of any inpatient services you receive from an out-of-plan provider; failure to inform Unity may result in a financial penalty. Not all services are covered when they are performed by an out-of-plan provider. In addition, some services require Prior Authorization when performed by an out-of-plan provider; failure to receive the necessary Prior Authorization will result in a monetary penalty. Review your Certificate of Coverage for more information. 27

30 I N F O R M A T I O N F O R P O S M E M B E R S Choice Plus Member Information The Choice Plus plan is a Point-of- Service (POS) product. You will receive the highest level of benefits (Level 1) by accessing care from in-network practitioners and providers. Level 1 You seek care from your in-network PCP or an in-network specialty provider. Level 2 If you have a PCP in Dane County (excluding the communities of Black Earth and Cambridge) and you receive care from certain specialty clinics within Unity s provider network that are not participating for you. Level 3 You access health care services from out-of-network providers. In-network for Choice Plus members includes all practitioners and providers listed in the Unity Network Provider Directory or the Find A Doctor section online at with the exception of certain specialty clinics if you have a PCP in Dane County (excluding the communities of Black Earth and Cambridge). Choice Plus members must select or be assigned an in-network Unity PCP. However, you are not required to seek services with or through your PCP, although your PCP can ensure you receive coordinated health care. Your health care services are subject to medical necessity, all benefit maximums, policy limitations and exclusions and eligibility requirements. If you receive services from out-of-network providers, coverage may be limited to usual, customary and reasonable charges. In Levels 2 and 3, you will have greater out-of-pocket expenses. Covered services received out-of-network will ALWAYS be payable under your Level 3 benefit. This excludes Emergency Room visits. Refer to your Schedule of Benefits or Summary of Benefits and Coverage, Prescription Drug Formulary and your Certificate of Coverage to determine your out-of-pocket expenses when receiving medical and pharmacy care. 28

31 I N F O R M A T I O N F O R P P O M E M B E R S Information for PPO Members How the Preferred Provider Organization (PPO) Plan Works As a PPO member, you have access to a wide variety of providers. Unity contracts with HealthEOS and PHCS (Multiplan), preferred provider organizations, to serve as the provider network. HealthEOS providers include hospitals, clinics and physicians throughout Wisconsin. PHCS (Multiplan) includes providers throughout the United States. HealthEOS and PHCS (Multiplan) providers can be found at by clicking Find A Doctor. You have a choice to either access participating providers or providers outside the network. If you receive care from an in-network provider, the provider will submit the claim on your behalf. When you receive care from an out-of-network provider, you are responsible for submitting a claim form to HealthEOS by MultiPlan within three months from the date the services were received. PPO Member Information The PPO plan offers two different benefit levels: In-Network You obtain services from providers in the HealthEOS or PHCS (Multiplan) networks. You receive the highest level of coverage (In-Network) when you see participating providers. Out-of-Network You receive services from providers outside the HealthEOS and PHCS (Multiplan) networks. Your health care services are subject to medical necessity, all benefit maximums, policy limitations and exclusions and eligibility requirements. Coverage for services received from out-of-network providers may be limited to usual, customary and reasonable charges. Not all services are covered when they are performed by an Out-of-Network provider. In addition, some services require Prior Authorization. Failure to receive the necessary Prior Authorization will result in a monetary penalty. Review your Certificate of Coverage for more information. 29

32 M E M B E R R I G H T S & R E S P O N S I B I L I T I E S Member Rights & Responsibilities Special Needs Unity is dedicated to assisting you in locating practitioners able to meet your special care needs. We encourage you to contact Unity Customer Service at regarding your special care needs. Your request will then be assessed by the appropriate staff. Unity also provides interpretation services in other languages for Unity members. Complaints and Grievance Resolution Unity is dedicated to providing quality service to its members. To continuously improve care and services, Unity looks to you for comments or suggestions. There may be a time when you have a complaint or concern regarding Unity benefits or service. As a member, you have the right to voice a complaint or appeal a decision made by Unity and to receive a prompt and fair review. If you have a complaint you would like addressed, please contact Unity Customer Service at Unity s customer service representatives are dedicated to resolving your complaint in a timely fashion. If Unity Customer Service is unable to resolve your complaint, the member advocate will assist you. Unity s grievance process includes a comprehensive review of your grievance by the member advocate and review by qualified medical personnel and the Reconsideration Committee when needed. The Reconsideration Committee was established to assure you receive all the benefits your contract entitles you to as well as a fair and impartial hearing of your grievance. This committee also provides you the opportunity to share information concerning your grievance in person. For certain types of claims, you are entitled to request an independent, external review of Unity s decision. You must request the review in writing by sending it electronically to [email protected], by faxing it to or by sending it by mail to P.O. Box 791 Washington DC If your claim is not eligible for independent external review but you still disagree with a denial, your state insurance regulator may be able to help to resolve the dispute. For questions about your rights or for assistance, you can contact: Office of the Commissioner of Insurance Complaints Department PO Box 7873 Madison WI or, if coverage is group health plan coverage the Employee Benefits Security Administration at EBSA (3272). For more information about your appeal rights, visit and select Members, Using Your Plan, Claims Process and then Appeals. Unity is dedicated to providing quality customer service and access to quality health care. Problems can be solved only when they have been identified. We thank you in advance for your cooperation. 30

33 M E M B E R R I G H T S & R E S P O N S I B I L I T I E S Take a moment to review your Member Rights and Responsibilities so you can continue to take a more active role in managing your family s health care: Member Rights To choose: Members have the right to choose a personal physician from Unity s network of Primary Care Physicians (PCPs). To obtain information: Members have the right to receive information about their rights and responsibilities as a member of Unity. Members have the right to make recommendations regarding Unity s Member Rights and Responsibilities Statement. Members have the right to obtain information about Unity and information relating to covered and excluded health plan benefits. Members also have the right to obtain information on available primary and specialty care practitioners and providers. Members have the right to receive preventive care information and information about their illnesses and treatment options. Members have the right to obtain information about how to file a complaint, appeal, or grievance. To have privacy and confidentiality: Members have the right to privacy and confidentiality in communications and records about their care. To participate in their care: Members have the right to be active in decisions about their treatments. Members have the right to have a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage. Members have the right to obtain information about the risks and benefits of treatment. Members also have the right to refuse care. To present a complaint, appeal, or grievance: Members have the right to voice concerns and to receive a prompt and fair review of their concerns. To be treated with respect and dignity: Members have the right to be treated with respect and dignity regardless of their race, age, gender, sexual orientation, or creed. Member Responsibilities To choose a personal physician: Members have a responsibility to choose a personal physician from among Unity s network of PCPs and to establish a relationship with that physician. To know their benefits and requirements: Members have a responsibility to understand their health plan benefits and limitations and to follow required procedures. Members also have a responsibility to know how to use Unity s provider network and to ask questions about things they do not understand. To provide accurate information: Members have a responsibility to provide accurate and complete information about their health history, their eligibility, and their enrollment. Members have a responsibility to show their ID card each time they receive services and to pay any out-of-pocket expenses they incur. To participate in their care: Members have a responsibility to participate in their care by asking questions about their health. Members also have a responsibility to follow the recommended and agreed upon treatment plan for their illness, and to make healthy lifestyle choices to maintain their health or manage their illness. To keep their appointments: Members have a responsibility to keep their appointments or to give early notice if they must cancel. To show consideration and respect: Members have a responsibility to show consideration and respect to health plan staff and health care providers. 31

34 M E M B E R R I G H T S & R E S P O N S I B I L I T I E S Confidentiality and Privacy Policies Unity has policies and procedures to protect the confidentiality of member information in oral, written and electronic form. Our Confidentiality Committee sets standards for Unity employees as well as external parties such as practitioners and providers. Unity also has a privacy official who monitors adherence to the policies. The Confidentiality Committee: Reviews internal and external requests for member information Identifies opportunities for reducing unnecessary collection of member data Monitors and regulates the use of member data The following is a brief summary about how Unity uses and protects member information. General Policy Unity has policies and procedures designed to safeguard the confidentiality of personally identifiable member information. These policies and procedures establish guidelines for the proper handling of records and information used to administer health plan benefits. When responding to a request for information, Unity s policy is to release only the information necessary to respond to the request. Authorization for Release of Information Unity does not need authorization to obtain or disclose member information for treatment, payment or health care operations. For other purposes, Unity will ask the member to sign an authorization form that gives permission to release the information. Authorization must be obtained when information is to be used for the following purposes: Release of information to a family member, power of attorney, employer or lawyer Release of information that could result in another company contacting you for marketing purposes Release of information for research (if the disclosure includes personally identifiable member information) In instances where a member is unable to provide necessary authorization, Unity will require a valid court order or other written proof of legal authority prior to releasing information. Member Access to Medical Records Unity does not maintain original medical records. Members may access their medical records by contacting their practitioner s office or the provider of care (such as a hospital). Members must follow the practitioner s or provider s procedures for accessing medical information. Disclosure of Information to Employers Unity provides certain types of information to employers as part of standard health insurance processes. Disclosure of information to employers is limited to the information the employer needs to administer the health plan. However, employers must agree not to use the information to make employment-related decisions (for example, promotion, hiring, lay-off) or to administer other benefit plans (for example, life and disability plans). The employer must identify persons or positions that may have access to the information and must ensure there are measures in place to prevent unauthorized access. Note: If you are covered by a Unity individual plan, we do not release information to your employer without a signed authorization f rom you. 32

35 M E M B E R R I G H T S & R E S P O N S I B I L I T I E S Treatment Setting Practitioners and providers are expected to implement confidentiality policies and procedures that address the disclosure of medical information, patient access to medical information and the storage and protection of medical information. Unity reviews practitioner confidentiality processes during pre-contractual site visits for primary care physicians and certain specialty care practitioners. Quality Improvement Data for quality improvement measures are collected from claims, pharmacy and member medical records. Unity protects confidential information by reviewing records in non-public areas and excluding member identifiable information from written reports. Opting Out of Information Sharing or Gathering You may have received notices from other organizations that allow you to opt out of certain disclosures. The most common type of disclosure that applies to opt outs is the disclosure of personal information to a non-affiliated company so that company can market its products or services to you. As a health plan, we must follow many federal and state laws that prohibit us from making these types of disclosures. Because we do not make disclosures that apply to opt outs, it is not necessary for you to complete an opt out form or take any action to restrict such disclosures. Unity s privacy and confidentiality policies protect member privacy and address the following topics: Routine use and disclosure of member health information Use of authorizations for non-routine disclosure of member health information Procedures used to monitor access to information Protection of information disclosed to external entities You may access Unity s Notice of Privacy Practices online at by selecting Privacy Practices & Policies. If you would prefer a printed copy, please call Unity s Privacy Official at , Ext or privacy.official@. Women s Health and Cancer Rights Act On October 21, 1998, Congress passed a law entitled the Women s Health and Cancer Rights Act of The Act requires all health plans offering mastectomy coverage to also provide benefits for the following services: Reconstruction of the breast on which the mastectomy was performed Surgery and reconstruction of the other breast to produce a symmetrical appearance Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedema Unity provides breast reconstruction benefits consistent with this law. Coverage for these services is subject to all of the same limitations, exclusions and cost-sharing provisions that apply generally to all other services provided under your health insurance plan. The copayment and deductible amounts that apply to your policy s surgical benefit also apply to the mastectomy and breast reconstruction benefits outlined above. Please consult your Certificate of Coverage and/or Schedule of Benefits or Summary of Benefits and Coverage for specific information. Questions about your health insurance benefits can be directed to Unity Customer Service at

36 Q U A L I T Y I M P R O V E M E N T P R O G R A M S Quality Improvement Programs Visit for more information on Unity s quality initiatives. Unity works to continuously improve the products and services it offers. In addition, Unity collaborates with its providers to improve the quality of care you receive and measures your satisfaction with the services it provided. Unity s success depends on your satisfaction. NCQA Accreditation Unity s goal is to give members the kind of service they need and deserve excellent service. This means offering access to physicians in many communities, rewarding members for working out and getting fit, providing information to help members make the most of their health plan benefits and answering the phones quickly when members call. In recognition of its ability to achieve this goal, Unity was awarded a fourth three-year Excellent Accreditation in 2010 for its Commercial HMO and POS products from the National Committee for Quality Assurance (NCQA). NCQA is an independent, not-for-profit organization dedicated to measuring the quality of America s heath care. The NCQA accreditation process is a nationally recognized evaluation system that purchasers, regulators and consumers can use to assess managed care plans. NCQA evaluates health plans on more than 60 standards, which fall into five broad categories: Access and Service Qualified Providers Staying Healthy Getting Better Living with Illness Achieving an Excellent rating means Unity meets or exceeds rigorous requirements for consumer protection and quality improvement. NCQA accreditation is a reflection of Unity s ongoing collaborative efforts and strong working relationship with its partner organizations. It shows Unity is dedicated to maintaining partnerships that are critical to the delivery of great health care. HEDIS Reporting HEDIS (pronounced hee-dis) stands for Healthcare Effectiveness Data and Information Set. HEDIS measures the quality of care and service a health plan delivers. HEDIS is a set of 76 measures that health plans use to measure their improvement from year to year. HEDIS measures performance in the following areas: Member health and use of preventive services Members ability to see the practitioners they need to see Member satisfaction with services received from Unity and medical care received from its providers Members ability to achieve good health Unity uses HEDIS results to identify clinical areas needing improvement. Programs to improve immunization rates, and breast and cervical cancer screenings rates are a few of Unity s preventive health projects. Unity also develops programs to help members with chronic diseases, such as asthma, diabetes and depression. The National Committee for Quality Assurance (NCQA) sponsors, supports and maintains HEDIS. * HEDIS is a registered trademark of NCQA. For specific information about NCQA, Unity s results and HEDIS results, please visit 34

37 Q U A L I T Y I M P R O V E M E N T P R O G R A M S Member Satisfaction Unity identifies service areas needing improvement from member surveys and calls received by Unity Customer Service. Unity conducts monthly and annual member surveys, including a survey on member satisfaction with behavioral health care. Unity also documents member phone calls. This information is used to identify opportunities to improve service. Evaluation of New Medical Technology The health care industry changes rapidly. The medical community develops new treatments and procedures regularly. Unity reviews new medical technologies (which includes new drugs) and new applications of existing technology to ensure members receive safe and effective care. Unity does not cover experimental or investigational treatments; however, your physician may decide a new technology is medically necessary to treat your condition. In this instance, your physician should contact Unity to request a medical review and to obtain additional information about the process. Unity s Medical Director will begin a thorough investigation. Unity s Technology Assessment Committee, made up of in-house resources and experts in the medical field, will review the information. This process takes the following criteria into account when reviewing new treatments or procedures: If government agencies have approved the technology or therapy for your specific disorder or condition If studies show the therapy improves overall health and is as good as other treatments Whether or not benefits of the new treatment or procedure are possible outside the research setting Whether or not the new treatment or procedure is in the testing stage, or is part of a research study After the review, the Technology Assessment Committee determines: If the service or treatment is experimental and/or investigational (as defined by Unity) If it is medically necessary If it is not excluded from coverage The Technology Assessment Committee then makes a decision regarding use of the experimental treatment or procedure for your condition. Unity will notify the member and his/her physician when a decision has been made. Unity members have the right to file a grievance (see page 30). The outcome is used by doctors and nurses who serve on Unity s Utilization Management Committee as guidelines to consider when they review future requests for coverage and benefits. Ensuring Quality Practitioners and Providers Unity works to ensure participating practitioners and providers are properly trained and licensed. This process is called credentialing. Credentialing means gathering and verifying information on a practitioner s medical license, education, hospital privileges and work experience. A trained professional also conducts a site visit and medical record review at PCP clinics and some specialty clinics. Practitioners must be credentialed before they treat Unity members. Credentialing is an important part of Unity s quality program. 35

38 G L O S S A R Y O F C O M M O N L Y U S E D M A N A G E D C A R E T E R M S Glossary of Commonly Used Managed Care Terms Access A patient s ability to obtain medical care as determined by factors such as the availability of medical services, his/her acceptability, the location of health care facilities, transportation, hours of operation and cost of care. Ambulatory Care Health services delivered on an outpatient basis such as when a patient makes the trip to the doctor s office or surgical center for treatment. Ancillary Care Additional health care services performed, such as lab work and x-rays. Authorization The approval of care, such as hospitalization; pre-authorization may be required before admission takes place or care is given by specialty care providers. Behavioral Health Diagnosis and treatment of mental health and/or substance abuse disorders. Benefit Specific health services provided to plan members as described in the employer group or subscriber contract, which could include primary care, hospitalization, outpatient care, ambulatory or emergency services. Benefit Year The 12-month period during which deductibles, out-of-pocket expenses and limitations accumulate. Capitation A per-member, monthly payment to a provider that covers contracted services and is paid in advance of its delivery. Care Management The process whereby a health care professional supervises the administration of medical or ancillary services to a patient or plan member. Certificate of Coverage Member Certificate issued to the plan subscriber of coverage which defines the benefits available to members (usually through their employer group contract) and the essential terms and conditions affecting eligibility, coverage conditions and termination of coverage. For members covered under the State of Wisconsin Health Insurance Program, the It s Your Choice: Decision and Reference Guides contains the complete description of their benefits. Claim Information submitted by a provider or covered member to establish that medical services were provided to a covered member from which processing for payment to the provider or covered member is made. Coinsurance The percentage of Unity s fee for medical services that are paid by the subscriber. Complaint An expression of dissatisfaction about an insurer, a health benefit plan, or an insurer s participating providers that is expressed to the insurer or the insured s authorized representative. Copayment A fixed amount paid by the subscriber for each office visit or pharmacy prescription filled. Covered See Benefit. Credentialing Examination of a health care practitioner s qualifications to determine admittance into a participating provider network or receipt of clinical privileges at a hospital. Deductible A fixed amount of money a member or family must pay before Unity will make a payment toward a covered service. Dependent An individual who receives health insurance through a spouse, parent or other family member. Disease Management Also called Health Management Helping members with an illness (usually chronic in nature) maintain their highest quality of life and utilize their health care resources in the best manner possible. Dual Choice The opportunity for a consumer within an employer group to choose from two or more different arrangements for the prepayment of health care services (usually a limited time each benefit plan year). Eligible Employee An employee who meets the requirements specified within the employer group contract to qualify for health benefit coverage. Employee Contribution The portion of the insurance premium paid by the employee for their health benefit coverage. Enrollment The process by which a health plan signs up individuals or groups as subscribers. Fee-for-Service Traditional provider reimbursement in which the physician is paid according to the service performed (system used by conventional indemnity insurers). 36

39 G L O S S A R Y O F C O M M O N L Y U S E D M A N A G E D C A R E T E R M S Fee Schedule The maximum amount of money Unity will reimburse noncontracted PCPs, specialists and hospitals for covered services rendered to My Choice members. Formulary A tool used by participating medical practitioners and pharmacists that lists quality, effective, safe and affordable prescription drugs covered by the health plan for those who have drug coverage. A formulary assists physicians and pharmacists in the management of drug solutions and promotes proper use of prescription drugs. Generic Drug A chemically equivalent copy designed from a brand-name drug whose patent has expired (typically less expensive and sold under the common name). Grievance Any dissatisfaction with the provision of services or claims practices of an insurer offering a health benefit plan or the administration of a health benefit plan by the insurer that is expressed in writing to the insured by or on behalf of an insured. Group A body of subscribers eligible for insurance by virtue of some common identifying attribute, such as a common employer, or a membership in a union, association or other organization. Group Contract The application and addenda, signed by both the health plan and the group, which constitutes the agreement regarding the benefits, exclusions and other conditions between the health plan and the enrolling unit. (A contract is usually limited to a 12-month period and subject to renewal thereafter.) High Deductible Health Plan (HDHP) A plan with federally-defined minimum deductible levels for single and family policies. Health Insurance A contractual relationship whereby an insurance company (the insurer) agrees to reimburse the insured for health care costs in exchange for a premium. The contract (policy) generally stipulates the type of health care benefits covered as well as costs to be reimbursed. Health Maintenance Organization (HMO) A form of health insurance in which members prepay a premium for health services and which generally includes a defined set of services made available through a defined panel of physicians for enrollees at a preset price. (For the member, it means reduced out-ofpocket costs and limited paperwork.) Hospital Affiliation A contractual agreement between an HMO and one or more hospitals whereby the participating hospital(s) provide the hospital care benefits offered by the plan. Health Savings Account (HSA) A tax advantaged savings vehicle subscribers can establish when they have a High Deductible Health Plan. Inpatient A patient admitted to a hospital who is receiving services under the direction of a physician for at least 24 hours. Medical Management An integrated working relationship between the managed care organization and the health care providers whereby medical protocols are established for the delivery of quality health care and the most positive clinical outcomes. Also known as care management or utilization management. Member One who is enrolled within a prepaid health program for health services through an individual or group contract (includes both subscribers and their enrolled dependents). Network A defined group of providers, typically linked through contractual arrangements, which supplies a full range of primary and acute health care services. Out-of-Pocket Expense Portion of health services or health costs that must be paid for by the plan member, including deductibles, copayments and coinsurance. Outpatient Services provided outside of a hospital, skilled nursing facility or other health care institution at the time services are accessed; or services provided at a health care facility but without being kept for 24 hours. Preferred Provider Organization (PPO) A health insurance plan in which members pay lower out-of-pocket costs when they receive care from providers participating in the network. Premium A fixed periodic payment for insurance coverage. Also referred to as rate. Preventive Care Health care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including age appropriate physical examinations, immunizations and well-person care. Primary Care Basic level of health care usually provided by family practice physicians, general practice physicians, internal medicine physicians, pediatricians, OB/GYN physicians and/or geriatric physicians. Usually provided in clinic settings (emphasis is on patient s general health needs). Practitioner An individual who supplies health care services, i.e., physician, psychologist, nurse practitioner. Provider A supplier of health care - services, i.e., pharmacies, hospitals or other health care facilities that provide services to members. Specialty Care Health care services provided by medical specialists who generally do not have the first contact with patients, but instead are referred to them by primary care and family physicians. Subscriber The eligible person in whose name a health insurance contract or insurance policy is held. Summary of Benefits and Coverage (SBC) or Schedule of Benefits A definition of health care benefits specifically identified as available to the enrolled member which includes the limit or degree of service that member is entitled to receive based upon his or her contract with a health plan or insurer. Usual, Customary and Reasonable (UCR) The allowable dollar amount for the same or similar services and supplies provided by health care providers within a geographic area. Utilization Review The process of evaluating the necessity, appropriateness and efficiency of the use of medical services, procedures and facilities. 37

40 840 Carolina Street Sauk City, WI Unity Customer Service Commercial HMO and POS UH00248 (0712) Unity Health Plans Insurance Corporation