Frequently Asked Questions

Employers/Group Administrators' Frequently Asked Questions about the UniCare PPO 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. This is only a brief summary of the plan. Please refer to certificates of coverage for more detailed information about the plan including benefits, conditions, limitations and exclusions.

• Products
• Pharmacy
• Provider Network
• ID Cards
• Physicians and Other Providers
• Approvals and Referrals
• Emergency Care
• Disabled Employees
• Coverage/Benefits
• Enrollment and Renewals
• Eligibility
• Notification of Changes
• COBRA
• HIPAA
• Premiums/Rates and Quotes
• Claims

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 offer an array of benefits products that address aspects of health care, prescription drug, dental, life and disability management, while satisfying the diverse needs of employers and associates. Our national network 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 research, plan and develop new solutions that respond to employers' evolving objectives.

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Pharmacy

2. Does a member have to purchase prescription drugs from a network pharmacy to receive UniCare benefits?

If the member is covered by the UniCare Prescription Drug Plan, he/she will receive benefits for covered prescription drugs purchased at in or out of network pharmacies. The member will usually pay less out of pocket if he/she purchases prescription drugs at network pharmacies.

3. How can a member 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.
• Consult a copy of the Provider Directory.
• 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, 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 the most commonly prescribed drugs on the formulary. Members can share this guide with their physicians and encourage them to prescribe generic or formulary brand name drugs (if no generic version exists) whenever possible.

5. Does a group or a subscriber within a group have to take prescription drug coverage?

A client does not have to offer drug coverage. However, if the plan a member is in covers both medical care and drugs, UniCare would not allow the member to pick and chose what coverages to take. The member would have to take both medical and drug coverage.

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Provider Network

6. Describe your provider networks.

MEDICAL:
UniCare's Platinum PPO network¹ includes coverage throughout the country. UniCare's Platinum PPO network includes many of the leading physicians, hospitals and other health care providers in the nation. This includes coverage both at home and when our members are traveling. Location specific information is available via the Provider Finder feature on our home page or by contacting your local UniCare Representative.

DENTAL:
Broad Network Access - Our large dental provider network offers members wide access to care. We are able to maintain our network size because of our flexibility. We have broad access to networks in our large metropolitan areas.

PHARMACY:
WellPoint Pharmacy Management² , a UniCare affiliate, currently serves over 27 million members and provides pharmacy benefit administrative services to many UniCare plans. The network is national in scope and includes over 52,000 pharmacies, representing 85% of all pharmacies in the nation.

¹Platinum Network is subject to applicable program terms and conditions and availability.
²Professional Claim Services, Inc. d.b.a. WellPoint Pharmacy Management

7. How often are your paper and online directories updated?

Directories are updated twice a year. Provider information is available online via our website, www.UniCare.com which is updated monthly. 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.

8. What is the difference between in-network and out-of-network?

When members choose to receive care from participants in a provider network affiliated with their UniCare PPO plan, they may pay less out of pocket and generally do not have to file claims.

When the provider is not a member of a UniCare-affiliated network, the member's share of the costs may be higher. In addition, many out-of-network providers may charge the patient in full, requiring the patient to submit a claim to UniCare in order to receive benefits.

9. How do I know what network is affiliated with my health plan?

The name of your network appears in the upper right hand corner of your UniCare identification card.

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ID Cards

10. 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.

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

11. 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.

12. Whose name and member ID/certificate number should appear on the ID card?

UniCare issues ID cards in the name of the subscriber and spouse. If the member's contract is a subscriber and child policy, we issue two cards in the subscriber's name. However, if the member calls customer service and requests a card for each member, the system will then generate a card in each member's name. The subscriber's certificate number will be on all cards.

13. 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 if 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.

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Physicians and Other Providers

14. 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 can be reached at the toll-free number on your identification card.

All of these sources can give the names, addresses, medical specialties, and hospital affiliations of network providers. The member can ask for providers in certain ZIP Codes that may be convenient to where he/she lives or works. In some cases, these sources can help identify physicians who speak languages other than English and give detailed directions from the home or workplace to the provider's location.

15. 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.

16. What are the advantages of using a network provider?

When members choose to receive care from hospitals and physicians in a participating network with their UniCare PPO plan, they may pay less out-of-pocket and generally do not have to file claims.

When the provider is not a member of a UniCare participating network, the member's share of the costs may be higher. In addition, out-of-network providers may charge the patient in full, requiring the patient to submit a claim to UniCare in order to receive benefits.

17. What happens if a current physician is not a network provider?

Call the provider or UniCare Customer Service to find out if the provider has joined the network since the website 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.

18. Can the member go to a non-network provider?

Yes, under a PPO, the member has out-of-network benefits. Generally, the UniCare PPO Health Plan covers the same health services whether he/she receives them in-network or out-of-network. The member will, however, usually pay higher out-of-pocket costs for out-of-network 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.

19. How can a member learn what services the health plan covers?

To learn more about what services the UniCare health plan covers, the member may log in to online Member Services and access his/her Benefits Detail. . In addition, the plan booklet will describe the covered services in the health plan. Covered services are the medically necessary procedures and types of care for which the plan will provide benefits. 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 detailed information about the plan including benefits, conditions, limitations and exclusions.

20. How do you recommend that a member choose a new physician?

In choosing a new physician, whether in-network or out-of-network, 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 hospital that the member prefers?
• Is that hospital in-network?
• 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?

21. 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.

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Approvals and Referrals

22. What if a member needs Specialists, Lab Tests or X-rays?

If a member or a covered dependent needs any of these services, he/she will not need a referral. If the member goes to a network provider, he/she may have fewer out-of-pocket expenses than with an out-of-network provider. If requested, network physicians can usually help refer the member to another provider in the network.

23. What if the member needs inpatient hospital care?

UniCare must certify all inpatient hospital admissions (those requiring an overnight stay in the hospital).

• For elective admissions, the member, the member's physician or a representative must obtain UniCare's certification before expenses are incurred. The person making the call should be prepared to give the UniCare ID number of the covered employee, the name of the patient (if different), the hospital or other provider location, and the full name, address and phone number of the attending physician.
• For emergency admissions, the member or a representative should notify UniCare within 48 hours of the admission.
• UniCare urges women to notify us in the first trimester of a pregnancy. In any case, hospitalization for maternity, like any planned inpatient admission, requires pre-certification two weeks in advance for a scheduled or full-term delivery. Emergency admissions for premature deliveries require notification within 48 hours.

If the member does not pre-certify those services which require notification, UniCare may reduce benefits or deny benefits altogether if the care is not deemed medically necessary.

Patients needing a hospital admission may pay less out-of-pocket if they select a network hospital.

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.

24. Do any other services require pre-certification?

The plan booklet will describe if the UniCare health plan requires pre-certification for certain 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 detailed information about the plan including benefits, conditions, limitations and exclusions.

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Emergency Care

25. What qualifies as an Emergency?

The definition of emergency care is found in the certificate of coverage and varies by plan, so please be sure to refer to the definition contained in your plan.

Emergency rooms are highly specialized health care facilities. When used for treating routine ailments, they represent the most expensive and wasteful health care option. Go to the emergency room only for 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 detailed information about the plan including benefits, conditions, limitations and exclusions.

26. What does a member do in case of an emergency?

If a member is faced with an emergency, he/she should always seek immediate care by going directly to the nearest emergency room or calling 911.

27. Do you cover emergency care?

UniCare covers emergency care. If faced with an emergency, a member should always seek immediate care by going directly to the nearest emergency room or calling 911. Benefits for covered emergency services will be the same whether or not the hospital is in-network or out-of-network. Many plans require a special copayment for emergency room care. The member makes the same copayment whether the emergency room is an in-network or out-of-network facility.

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.

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Disabled Employees

28. I have an employee out on disability. How long am I required to keep them on the group health insurance policy?

UniCare's standard fully insured large group policies state that if a qualified employee's insurance ceases because of disability, his or her insurance may be continued at the Plan Sponsor's option subject to (1) below. This continuation will be at the Plan Sponsor's option, but must be according to a plan which applies to all employees in the same way.

If a qualified employee's insurance ceases:
(1) due to a disability, his or her insurance may be continued until the qualified employee is no longer disabled.

Please refer to the applicable certificate for more detailed information.

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Coverage/Benefits

29. Will UniCare send out detailed benefit information to employees?

Yes. The employer receives a supply of EOCs (evidence of coverage booklets) to issue to employees enrolled in the plan.

30. What are pre-existing conditions and how do they impact coverage?

Please reference your plan booklet for information in any applicable pre-existing condition limitations on coverage and/or other pre-existing condition provisions.

31. What type of wellness or health promotion programs do you offer to your members?

HealthyExtensions^SM is a personal path toward creating a healthier lifestyle. UniCare believes there are many components to a member's health and well-being. Through independent vendors³ HealthyExtensions^SM builds on existing UniCare prevention and wellness benefits by providing members with access to a large selection of materials, services and products for health and fitness at special discounted rates, including:

UniCare'S MedCall® puts the power of information at our member's fingertips whenever and wherever they need it so they can become better-informed health care consumers. This telephone information service puts the member in touch with nurse counselors who can answer any health care questions toll-free. This service includes an audio library with over 200 audio tapes covering a wide range of health topics as well the Healthwise Knowledgebase. Healthwise is a comprehensive resource of decision-making information created for medical consumers.

UniCare's Employee Assistance Program offers members and their families confidential help provided by professional consultants. Help is available for difficulties relating to relationships, substance abuse, stress and emotional problems. Also, the EAP website offers quick tips on life balancing issues.

UniCare offers a free glucose monitoring system through our Glucometer Program, at no charge to our members. Because routine monitoring of blood glucose levels is essential in minimizing the risk of complications and in maintaining the good health of our members.

³The HealthyExtensions^SM independent vendors are not affiliated with UniCare, its affiliates or parent companies.

32. When traveling, can my employees receive coverage out-of-area?

The member or covered family member needing care may go to any doctor or facility wherever they are and receive covered services, subject to out-of-network benefits .⁴

In addition, UniCare's Platinum PPO network⁵ members, can receive in-network benefits from any provider in UniCare's Platinum network all across the country. To access Platinum network travel access benefits, the member can call the travel access phone number on the back of the ID Card and the travel access representative will help find a provider and can even help make your appointment. This benefit is available when away from home on vacation or on business and is also available to students at school away from home.

If the member is not part of UniCare's Platinum network, he/she can call the toll-free customer service on the ID Card and a UniCare representative will let the member know if the type of care he/she needs is available in the area where you he/she traveling. Typically only hospital care is available to members who do not have access to the Platinum PPO.

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.

⁴ Limited to the United States.
⁵ Platinum network is subject to applicable program terms and conditions and availability.

33. Do you issue policies to minors?

UniCare's large group policies are issued to the employer not to individuals.

34. When does coverage begin?

The date UniCare coverage begins depends on if the account is eligible on day 1, and also if the account has a waiting period. The contract defines the date coverage will begin.

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Enrollment and Renewals

35.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.

Additional information may be required.

36. Does the renewal paperwork require signatures from the broker and/or the group, if there are no changes other than the renewal rates?

Yes, the renewal paperwork will require signatures from the broker and/or the group.

37. What are the enrollment deadlines for a new group?

Enrollment deadlines depend on how the information is provided, i.e., electronic, paper. The standard is 15 days from effective date (and all paperwork is submitted).

38. 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.

39. Can I e-mail enrollment files to the plan?

Although enrollment files cannot be accepted via email, we would accept online eligibility maintenance through myunicareonline.com after the case is initially enrolled.

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Eligibility

40. What is the average turnaround time required to determine a group or a subscriber's eligibility or underwriting status?

The client determines if member is eligible, subject to UniCare approval. Typical processing once enrollment is received is 3 business days turnaround time. Please note, processing time varies.

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Notification of Changes

41. Who must be notified of a change of address or other administrative change?

From a contractual standpoint, the UniCare Account Manager should be notified of any changes. The Account Manager completes the applicable paperwork needed to facilitate the changes.

42. How do I change the waiting/elimination/probationary period on a group's policy?

Request for amendment (signed by the contract holder) 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.

43. What is the maximum waiting/elimination/probationary period a group can impose?

The maximum period is six months to a year, depending on the employer's human resource policies..

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COBRA

44. Does COBRA coverage count as creditable coverage?

Yes, COBRA counts as creditable coverage.

45. 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.

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HIPAA

46. 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.

47. How does crediting for preexisting condition 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 a category 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.

48. 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

49. 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.

50. 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.

51. 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.

52. 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.

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Premiums/Rates and Quotes

53. Is payment required at the time of application?

Yes, payment equal to one month of premium is required at the time of application.

54. How do I obtain a small group quote? (less than 50 employees)

For a more information on UniCare small group plans, please call 1(800)-UniCare.

55. How do I obtain a large group (51+ employees) quote?

To obtain a large group quote, call your broker or consultant or call 1(800)-UniCare for a sales representative near you.

56. What percentage of premium does the employer have to contribute?

The employer would typically contribute 75% of the premium.

57. Can a small group (less than 50 employees) get lower rates if they do not use a broker?

For a more information on UniCare small group plans, please call 1(800)-UniCare.

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Claims

58. How are claims handled for employees with more than one health insurance plan?

UniCare 's plans contain the standard coordination of benefits language when their enrollees are covered under two or more group health plans.

59. When will my employees need to file a claim?

For UniCare PPO members that go to a network provider, no claim form is necessary. If a PPO member seeks care at a non-network provider, a claim form may be required. You may call the customer service number on the ID card or contact us through online Member Services if you need additional information.

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.

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