- Employers
- Frequently Asked Questions
- Large Group HMO
Frequently Asked Questions
Employers/Group Administrators' Frequently Asked Questions about the UniCare HMO Health Plan
The topics below contain a broad list of group administrators' Frequently Asked Questions. Please use the links below to refine your search, or simply scroll down to locate the subjects of most relevance to you. The answers are only general descriptions of coverage. Please refer to certificates of coverage for more complete details about the plan including benefits, conditions, limitations and exclusions
- Products
- Pharmacy
- Provider Network
- ID Cards
- Physicians and Other Providers
- Approvals and Referrals
- Emergency Care
- DisabledEmployees
- Coverage/Benefits
- Enrollment and Renewals
- Eligibility
- Notification of Changes
- COBRA
- HIPAA
- Premiums/Rates and Quotes
- Claims
- NCQA
- HEDIS
Products
1. What products and services do you offer?
UniCare understands that offering a variety of products is essential in developing a competitive associate benefits program. We offeran array of benefits products that addressaspects of health care, prescription drug, dental, life and disability management, while satisfying the diverse needs of employers and associates. Ournetwork management program is an evaluation program of managed care guidelines and performance outcome measures that monitor each network and network provider for quality and cost-efficiency. Our Healthcare Quality Assurance (HQA) program maximizes Plan Performance by managing the health care costs of the people who use it the most. UniCare's line of diverse products are designed to meet the needs of your organization. We pride ourselves on being an innovative organization that anticipates changing health care benefits dynamics and employer needs. We constantly strive to research, plan and develop new solutions that respond to employers' evolving objectives.
2. Describe UniCare's Health Improvement Resources.
To help associates take charge of certain chronic conditions and live a better, more productive life, UniCare offers Health Improvement Programs.
Unlike traditional programs that offer a one-size-fits-all standardized outreach and education approach, UniCare Health Improvement Programs focus more on outreach that is targeted toward the individual’s personal lifestyle. This concept, known as “Health Coaching,” pairs a team of health professionals (which may include RN’s, dieticians, exercise physiologists, social workers, etc.) with the participant and their health care providers to decide which behaviors they would like to work on first. Then the participant receives education and support geared toward these goals. The final decision about what program is appropriate for the participant is left to the individual and their physician.
Health Improvement Programs are available for a variety of chronic conditions, including asthma, diabetes and chronic heart failure. Health Improvement Programs are subject to change or discontinuation with notice.
Pharmacy
3. How can I find a network pharmacy?
Below are the ways to locate network pharmacies
- Consult the Provider Finder on this Web site. It allows you to search by pharmacy name, city, state or ZIP code. Most listings provide maps and driving directions to the pharmacy.
- Call the toll-free customer service telephone number on the identification card.
- Some editions of UniCare's prescription drug plan member handbooks list some of the large national chain pharmacies that participate in UniCare's network.
In addition, a member can always inquire at any pharmacy of your choice if they accept UniCare. It will help if you show them the UniCare identification card.
4. What is a drug formulary?
A formulary is a list of effective, affordable and commonly prescribed medications, comprised of brand name and generic drugs. Your plan may feature a formulary to encourage members to use quality, more affordable prescription medications. If the plan does include a formulary, the member may pay a lower copayment when the independently contracted physician prescribes formulary drugs. Some plans may limit coverage to drugs on the formulary.
The complete drug formulary is usually quite long and technical. UniCare distributes a Formulary Selection Guide that lists commonly prescribed drugs on the formulary. Members who wish to keep their out-of-pocket costs at a minimum should share this guide with their independently contracted physicians and encourage them to prescribe generic or formulary brand name drugs (if no generic version exists) whenever possible.
This is only a brief summary of the plan. Please refer to the certificate of coverage for more complete details about the plan including benefits, conditions, limitations and exclusions.
Provider Network
5. Describe your provider networks.
UniCare Health Plans of the Midwest, Inc.'s network serves 9 counties in the Chicago Metropolitan Area in Illinois and Northwest Indiana. The HMO network includes over 2,500 Primary Care Physicians and over 5,000 specialty care physicians. Complimenting the physician network UniCare HMO includes 93 hospitals and an extensive network of 600 ancillary health care institutions and professionals.
UniCare Health Plans of Texas, Inc. 's network covers 44 counties with over 1,300 Primary Care Physicians, 2,300 Specialists, 38 hospitals, and over 400 pharmacy locations. The provider network is comprised of one large physician group (Kelsey-Seybold Clinics) and several other individual physician associations such as: Baylor MedCare, Baylor-Methodist Primary Care Associates, Advanced IPA, Greater Houston Intercultural, Houston Metropolitan Health Network, Texas Children's Health Plan, University of Texas Galveston University Care Plus and other fine independent physicians throughout the greater Houston, Galveston, Beaumont and southeast Texas communities.
6. How often are your paper and online directories updated?
Paper Directories are updated annually and online directories are updated monthly. Provider information is available online via our website, www.UniCare.com. Through our online provider finder feature, members have the ability to print a listing of providers in their area. In addition, employees may also call Customer Service at anytime for questions regarding a physician's participation.
ID Cards
7. How does the member use his/her UniCare identification card?
The identification (ID) card is the member's passport to UniCare health plan benefits. Presenting the ID card in a physician's office or hospital admissions office enables the provider to confirm that the member is eligible for benefits. The name of the member's Primary Care Physician is displayed on the ID card.
The ID card lists one or more toll-free telephone numbers that will link the member or provider to UniCare staff if the member needs to:
- Pre-certify required inpatient hospital admissions and any other services specified in the member's plan booklet.
- Report an emergency hospital admission.
- Ask a question about benefits or a specific claim.
- Access UniCare's health information, case management or health promotion services that are available.
This is only a brief summary of the plan. Please refer to the certificate of coverage for more complete details about the plan including benefits, conditions, limitations and exclusions.
8. Who may use the UniCare ID card?
Only the member and covered family members enrolled through the employer may use their member ID card and receive plan benefits. A member should never lend his/her ID card to anyone.
9. Whose name and member ID/certificate number should appear on the ID card?
Each individual member's name will appear on the ID card, but the subscriber's certificate number will be on all cards
10. What if a member loses his/her ID card or needs to order additional cards?
If the member loses his/her UniCare ID card and needs a replacement, or the member would like to order additional ID cards, the member may call our toll-free customer service number or notify you [the company's benefits administrator] immediately. The member may also go to online Member Services or call the toll free number on the back of the ID card. The card will normally be delivered within 7 working days from the time the request is placed. If medical care is required before ID cards are received, the member should give the provider of care the certificate number that was used to access the member's account.
Physicians and Other Providers
11. How can a member find the names, addresses and other important information concerning physicians, hospitals and other health care providers in the network?
There are three sources:
- The Provider Finder on this Web site
- The Network Provider Directory
- UniCare's Customer Service, which you can reach at the toll-free number on your identification card.
All of these sources can give the member the names, addresses, medical specialties, and hospital affiliations of network providers. He/she can ask for providers in certain ZIP Codes that may be convenient to where the member lives or works. In some cases, these sources can help identify physicians who speak languages other than English and give detailed directions from home or workplace to the provider's location.
12. What if a provider a member would like to use is not listed in the Provider Finder or the Network Provider Directory?
The member can call the provider or UniCare Customer Service to find out if the provider has joined the network since the Web site information was last updated or the directory was last printed.
If the provider is not in the network, the member may nominate him or her via e-mail through the link provided in the FAQs option on the Provider Finder or by calling Customer Service.
Nomination is a process for UniCare to receive information about the providers that members would like in the network. Please note, it does not mean the provider will become a participating provider.
13. What if a member's provider has left the network since the Provider Finder was last updated or the directory was last printed?
If a Primary Care Physician has left the independently contracted network, the member should select a new provider and contact Customer Service with the new selection. Customer Service will send a new ID card with the new independently contracted Primary Care Physician's name and telephone number.
14. How can a member learn what services the health plan covers?
To learn more about what services the health plan covers, the member may log in to online Member Services and access his/her Benefits Detail. In addition, the plan booklet will briefly describe the covered services in the health plan. The limitations and exclusions section of the booklet will describe types of care that the plan does not cover. The booklet will also indicate if there are services that require pre-certification from UniCare before the patient receives care and any services that may be restricted to an annual or lifetime maximum benefit.
This is only a brief summary of the plan. Please refer to the certificate of coverage for more complete details about the plan including benefits, conditions, limitations and exclusions.
15. What are the out-of-pocket costs that a member may have to pay?
The benefit summary in the plan booklet specifies the amounts and the types of out-of-pocket charges for covered services. Depending on the service and the provider, the member may have to pay for example, a copayment, which are amounts for non-covered expenses.
This is only a brief summary of the plan. Please refer to the certificate of coverage for more complete details about the plan including benefits, conditions, limitations and exclusions.
16. What are some considerations a member may have to choose a new physician?
In choosing a new physician, the member may want to consider:
- Is the physician's office location convenient to his/her home or workplace? UniCare's Provider Finder supplies maps and driving directions for most network provider locations.
- Does the physician have admitting privileges at a (network) hospital that the member prefers?
- Does the physician have office hours that fit in with the member's schedule?
- If English is not your primary language, does the physician speak the language you prefer?
- Is the physician board-certified?
- Do you have friends or colleagues who recommend the physician from first-hand experience?
17. What if a member cannot keep his/her appointment?
UniCare does not cover charges for broken appointments. The member should always try to keep an appointment or notify the independently contracted provider in plenty of time if he/she must cancel.
Approvals and Referrals
18. Does UniCare cover visits for specialty care?
Yes, the UniCare HMO plan covers visits for specialty care. Because the member's primary care physician (PCP) is responsible for coordinating all health care, members should discuss their health care concerns and any medical treatment with their PCP. When specialty care is needed, the PCP will refer members to a specialist.
19. Does UniCare require that a member obtain a referral for OB/GYN services?
A female member may receive routine OB/GYN services from a woman's principal health care provider without a referral from her PCP. To do so, she must first designate the woman's principal health care provider. Remember the woman's principal health care provider must have a referral relationship with the member's PCP. Members may confirm a referral relationship by accessing UniCare's Customer Service department, the provider directory or the provider listing on the website.
20. What if the member needs Specialists, Lab Tests or X-rays?
If the member or a covered dependent needs any of these services, the member will need to get a referral from his/her independently contracted Primary Care Physician.
21. What if the member needs inpatient hospital care?
If the member needs to be hospitalized, the independently contracted Primary Care Physician will arrange for admission to an independently contracted network hospital. The independently contracted Primary Care Physician will also continue to be responsible for overseeing the administration of care.
The hospitalization in most instances must be referred by the independently contracted Primary Care Physician and authorized by UniCare HMO (when applicable) in order for the member to receive benefits for eligible services.
This is only a brief summary of the plan. Please refer to the certificate of coverage for more complete details about the plan including benefits, conditions, limitations and exclusions.
22. Do any other services require pre-certification?
The plan booklet will describe if the UniCare health plan requires pre-certification for certain items, for example, outpatient diagnostic tests and surgical procedures or for services like home health care or skilled nursing facility admissions. Procedures for obtaining pre-certification for these services, if required, are the same as for inpatient admissions.
This is only a brief summary of the plan. Please refer to the certificate of coverage for more complete details about the plan including benefits, conditions, limitations and exclusions.
Emergency Care
23. What qualifies as an Emergency?
The definition of emergency is found in the certificate of coverage and varies by plan. Please be sure to refer to the definition contained in your plan.
Emergency rooms are highly specialized health care facilities. A member should go to the emergency room only for true emergencies, not for routine ailments or for convenience.
Emergencies can vary widely. Some examples of medical emergencies are:
- Possible heart attack (severe chest pain or pressure)
- Uncontrollable bleeding
- Confusion or loss of consciousness, especially after a head injury
- Severe shortness of breath or difficulty breathing
- Severe or multiple injuries, including obvious fractures
This is only a brief summary of the plan. Please refer to the certificate of coverage for more complete details about the plan including benefits, conditions, limitations and exclusions.
24. What does a member do in case of an emergency?
If a sickness or injury is an emergency and immediate medical attention is a must, the member should go directly to the nearest emergency facility or call 911. Within 24 hours of emergency treatment, the member should call his/her independently contracted Primary Care Physician. We also ask that the member call Customer Service on the first business day following any emergency room visit. This will make it easier to assure that the bill for any "eligible" charges is paid promptly. It also means that the independently contracted Primary Care Physician will be able to coordinate any further care
This is only a brief summary of the plan. Please refer to the certificate of coverage for more detailed information about the plan including benefits, conditions, limitations and exclusions.
25. Do you cover emergency care?
Members and their families have coverage for covered medical emergencies both in and outside of the UniCare HMO service area.
In emergencies, the member should always go directly to the nearest emergency facility or call 911.
A copayment may apply to treatment received in a hospital emergency room - but this may be waived if the member is admitted from the emergency room to the hospital for inpatient care. The member should check the member ID card for the amount of the copayment, if any.
To access benefits for covered urgent care and/or after hours care, the member should always call his/her independently contracted Primary Care Physician's office first; the phone number is on the member ID card. The independently contracted Primary Care Physician or colleague will be on call 24 hours a day, 7 days a week to help, whether that means authorizing a trip to the emergency room or making other arrangements. In emergencies, the member should always go to the emergency room.
This is only a brief summary of the plan. Please refer to the certificate of coverage for more detailed information about the plan including benefits, conditions, limitations and exclusions.
Disabled Employees
26. I have an employee out on disability. How long am I required to keep them on the group health insurance policy?
This is determined on a per case basis, based on the contract with UniCare. For more information, please contact your account manager.
Coverage/Benefits
27. Will your plan send out detailed benefit information to employees?
New members will receive a "New Member packet" which will contain the UniCare HMO member certificate, Member Handbook and benefit summary.
28. What are pre-existing conditions and how do they impact coverage?
Neither UniCare Health Plans of the Midwest, Inc. nor the UniCare Health Plans of Texas, Inc. have pre-existing restrictions.
29. Do you issue policies to minors?
UniCare's Large Group policies are issued to the employer not to individuals.
30. When does coverage begin?
Coverage begins once the member has satisfied the employer waiting period, if applicable.
31. What type of wellness or health promotion programs do you offer to your members?
The UniCare Preventive Health Services & Education department provides wellness services to UniCare Health Plans of the Midwest, Inc. members through worksite preventive health programs at the employer group site and in the community. The worksite preventive health services provide members with educational information on various health topics, seminars on preventive health issues, health risk assessments, experiential learning centers targeting heart health, men's and women's health, complementary medicine, fitness, nutrition/weight management and stress management. To learn more about the Preventive Health Services & Education department members may call 1-877-217-8062 for information on the worksite and community services along with tobacco cessation. Healthy Living, a section of this website, is available to all members and includes a wealth of information through health articles and information on local and national health resources.
UniCare Health Plans of Texas, Inc. is evaluating existing programs for consideration in their growing market base.
32. When traveling, can my employees receive coverage out-of-area?
With UniCare HMO members have coverage for emergency care.
If a member has a life-threatening or severe medical emergency when he/she is away from home, the member should seek treatment immediately at the nearest emergency medical facility. The member should inform the hospital or physician that he/she is a member of a UniCare HMO and, to make it easier to assure that any bill for covered services is paid promptly, the member should call 1(888) 234-8855 (follow the voice prompts) within 24 hours after medical care begins.
Urgent problems are illnesses or injuries that require medical attention before the member can return to see his/her primary care physician, or problems that make traveling to the UniCare HMO service area inadvisable. Some examples of problems requiring urgent care include ear infections, bladder infections and sprained ankles.
In the event of an urgent illness or injury that is not an emergency, the member must call 1.888.234.8855 (follow the voice prompts) before seeking treatment in order for that treatment to be eligible for coverage.
Once the member's condition has improved so that he/she is medically able to travel, the member must receive and ongoing of follow-up care in the UniCare HMO service area through the member's primary care physician in order for services to be eligible for coverage.
Enrollment and Renewals
33. What documentation is necessary for enrolling a group?
At a minimum, the following documentation is necessary for enrolling a group: application, binder check, must offer forms, new case installation paperwork and enrollment forms. Your sales representative will notify you of any additional requirements.
34. Does the renewal paperwork require signatures from the broker and/or the group, if there are no changes other than the renewal rates?
No, the renewal paperwork does not require signatures from the broker and/or group if there are no changes other than renewal rates.
35. What are the enrollment deadlines for a new group?
Enrollment deadlines are 15 days for key accounts with 51-250 employees, prior to the effective date and 21 days prior to effective date for major accounts with 251- 2000 employees.
36. How do I submit enrollment files to the plan?
You may submit enrollment files to the plan on paper or electronically (tape 750+ employees). After the case is initially enrolled we would accept online eligibility maintenance through myunicareonline.com.
Eligibility
37. What is the average turnaround time required to determine a group or a subscriber's eligibility or underwriting status?
The client determines if a member (subscriber) is eligible. Standard processing time, once enrollment is received, is 3 days turnaround time.
Notification of Changes
38. Who must be notified of a change of address or other administrative change?
The premium specialist or account manager should be notified by the benefits administrator of any administrative changes or changes to the company address.
39. How do I change the waiting /elimination/probationary period on a group's policy?
Request for change can be submitted to the account manager who will work with underwriting to determine if the change is approved and determine effective date of change.
40. What is the maximum waiting/elimination/probationary period a group can impose?
A waiting period pursuant to HIPAA "is the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan".
COBRA
41. Do I have to offer COBRA to terminating employees or their dependents?
Yes, as mandated by Consolidated Omnibus Budget Reconciliation Act of 1985, the federal law that requires employers with more than 20 employees to extend group health insurance coverage, you must offer COBRA to terminating employees.
HIPAA
42. Who is eligible for HIPAA?
The provisions of HIPAA generally apply to group health plans and group health insurance issuers offering group health insurance coverage. This means that both the plan itself and the insurer (if any) are required to comply. HIPAA contains many exceptions, including exceptions for the following types of plan:
- Plans with fewer than 2 employees;
- Plans providing only certain incidental types of coverages, including accident, disability income, liability insurance, and workers compensation;
- Plans providing limited scope dental or vision benefits if provided under separate insurance policy or if coverage is elected by participants separately from the medical coverage;
- And health FSAs, if certain requirements are met.
43. How does crediting for pre-existing exclusions waiting periods work under HIPAA?
Many plans use the "standard method" to credit coverage. The individual receives credit for previous coverage that occurred without a break in coverage of 63 days or more. Coverage prior to a 63 day break or more is not credited against a preexisting condition exclusion period.
A plan or issuer may elect the "alternative method" for crediting coverage for all employees. The plan or issuer determines the amount of an individual's creditable coverage for any of the five specified categories of benefits which are mental health, substance abuse treatment, prescription drugs, dental care and vision care. The standard method is used to determine an individual's creditable coverage for benefits other than the five categories that a plan or issuer may use. (The plan or issuer may use some or all of these categories).
With the alternative method, the plan or issuer looks to see is an individual has coverage within acategory of benefits (regardless of the specific level of benefits provided within that category).
If your employer's plan requests information from your prior plan regarding any of the categories of benefits under the alternative method, your former plan must provide such information.
44. How will the latest HIPAA requirements regarding security, privacy, etc. affect the products your plan offers?
The requirements do not affect the products offered, however, they do affect the way UniCare does business. UniCare's practices and procedures are in compliance with HIPAA requirements
45. What qualifies as creditable coverage?
Most health coverage is creditable coverage, such as coverage under a group health plan (including COBRA continuation coverage), HMO, individual health insurance policy, Medicaid or Medicare.
Coverage consisting solely of "excepted benefits," such as coverage solely for limited-scope dental or vision benefits is not included as creditable coverage.
Days in a waiting period during which you have no other coverage are not creditable coverage under the plan, nor are these days taken into account when determining a significant break in coverage (generally a break of 63 days or more). This 63-day break period may be extended under state law if your coverage is insured through an insurance company or offered through an HMO.
46. How does an employer-imposed waiting period affect a break in coverage?
A period of creditable coverage shall not be counted if it is before a significant break in coverage if, after such period and before the enrollment date, there was a 63 day period during all of which the individual was not covered under any creditable coverage. A waiting period is not treated as a break in coverage. Any period that an individual is in a waiting period for any coverage under a group health plan (or for group health insurance coverage) or is in an affiliation period shall not be taken into account in determining the continuous period.
47. How does a new employer or insurance carrier know that an employee had prior group coverage?
Group health plans and health insurance issuers are required to provide a certificate of coverage to an individual for documentation of prior creditable coverage. A certificate of creditable coverage shall be provided automatically by the plan or issuer when an individual either loses coverage under the plan or becomes entitled to elect COBRA continuation coverage and when an individual's COBRA continuation coverage ceases and shall also be provided, if requested, before the individual loses coverage or within 24 months of losing coverage.
48. How will newly hired employees prove that they had prior creditable coverage?
Under HIPAA, an employee's former group health plan and any insurance company or HMO providing such coverage is required to provide the employee with a statement of prior health coverage, commonly referred to as a "certificate of creditable coverage. "
This certificate must be provided automatically to the individual when the individual loses coverage under the plan or otherwise becomes entitled to elect COBRA continuation coverage as well as when COBRA continuation coverage ceases.
An individual may also request a certificate, free of charge, until 24 months after the time their coverage ended. For example, an individual may request a certificate even before your coverage ends.
Premiums/Rates and Quotes
49. Is payment required at the time of application?
Yes, the first month's premium is due prior to case set up.
50. How do I obtain a small group quote? (less than 50 employees)
For a small group quote, please call 1(800)-UniCare.
51. How do I obtain a large group quote?
To obtain a large group quote, you would submit an RFP or RFI or census information to the assigned Sales Representative or Vice President of Sales and Marketing. Call 1-800-UniCare, or Select Your State to see region-specific plan offerings and contact information.
52. What percentage of premium does the employer have to contribute?
The employer would typically contribute 75% of the premium for single coverage and 0% for family coverage.
53. Can a small group get lower rates if they do not use a broker?
For a more information on UniCare small group plans, please call 1(800)-UniCare.
Claims
54. How are claims handled for employees with more than one health insurance plan?
Health benefits are coordinated with any other health insurance plan in effect at the time services are rendered, to ensure the total benefits paid by UniCare and any other group health plan do not exceed 100% of the allowable expenses. Order of Benefit Determination follows any existing legislation, whether Commercial insurance or Medicare. Members are responsible for providing the plan with details regarding other coverage for any & all family members, so claims can be coordinated appropriately.
The member's enrollment form asks for information about any other group coverage for which the member or any other family members may be eligible. Claims analysts use this information to coordinate benefits between other insurance carriers and UniCare. It is also used to identify the carrier that has the primary responsibility for covering medical services.
55. What should my employee do if a claim is denied?
Any question about the disposition of a claim can be directed to Customer Service at the phone number listed on the employee's identification card.
56. When will my employees need to file a claim?
HMO members are normally not required to file a claim form in most instances.
This is only a brief summary of the plan. Please refer to the certificate of coverage for moredetailed information about the plan including benefits, conditions, limitations and exclusions.
NCQA
57. Is UniCare NCQA accredited?
UniCare Health Plans of the Midwest, Inc. has been granted a full three-year Excellent Accreditation by the National Committee for Quality Assurance, it’s highest rating. This achievement demonstrates UniCare’s commitment to providing quality health care benefits and services to employers and to members. NCQA accreditation is a voluntary process. The surveys include rigorous on-site and off-site evaluations of over 60 standards and selected HEDIS® performance measures. A team of physicians and managed care experts conducts the accreditation surveys. A national oversight committee of physicians analyzes the team’s findings and assigns an accreditation level based on the performance level of each plan being evaluated to NCQA’s standards.
HEDIS
58. Does UniCare participate in HEDIS data collection?
UniCare Health Plans of the Midwest, Inc. has participated in HEDIS data collection and reporting for its HMO plan for a number of years. The Plan recognizes HEDIS as an important tool for the managed care industry as it addresses a full spectrum of health care issues from prevention and early detection to acute and chronic care. HEDIS also serves as a helpful tool for employers and members when accessing the competency level of a managed care plan. The HEDIS program is sponsored and maintained by NCQA, an independent non-profit organization that measures and evaluates the effectiveness of managed care. HEDIS was developed by a committee of health care consumers, providers, public health officials and others. HEDIS measures a plan’s performance in several key areas, including effectiveness of care, stability of the health plan, accessibility/availability of care, membership and satisfaction, and use of services.
