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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, limitations and exclusions. In case of any discrepancies between the information contained in these FAQs and the most recent edition of the Certificate of Coverage, the terms of the Certificate of Coverage shall govern.

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 a complete array of benefits products that address all aspects of health care, prescription drug, dental and life, while satisfying the diverse needs of employers and employees. There are also many specialty products and services including:

  • Defined Contribution Options for both medical and dental coverage;
  • Discounts on a variety of alternative health care and wellness products and services through HealthyExtensions;
  • Access to MedCall® – a 24-hour health information hotline;
  • A Premium Only Plan, through Ceridian Benefits Services, which enables employees to pay their share of benefits with pre-tax dollars while allowing employers to decrease their payroll taxes.

UniCare’s strategy of providing freedom of choice and superior service has garnered strong consumer appeal and industry-wide attention. Consumers also find a commitment to customer service and to reducing health costs without sacrificing quality or choice of physicians.

Medicare supplement policies are available in Illinois, Indiana and Virginia. Unfortunately, Medicare supplement policies are not available on Texas.

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Pharmacy

2. How can a member find a network pharmacy?

Described 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 their choice as to whether they accept UniCare. It will help if the members show them their UniCare identification card.

3. 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 physician prescribes formulary drugs. Some pharmacy 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 physicians and encourage their doctors to prescribe generic or formulary brand name drugs (if no generic version exists) whenever possible.

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Provider Network

4. Describe your provider networks.

UniCare’s Illinois HMO 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’s Texas HMO 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 two large physician groups (Kelsey-Seybold Clinics and MacGregor Medical Association) 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.

5. 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.

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ID Cards

6. 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 complete details about the plan including benefits, limitations and exclusions.

7. 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.

8. 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. In addition, a separate card will be issued to any member of the family who has an IPA or PMG affiliation that differs from the subscriber. The subscriber's certificate number; usually the subscriber's Social Security number will be on all cards.

9. 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.

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Physicians and Other Providers

10. 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 you the names, addresses, medical specialties, and hospital affiliations of network providers. You can ask for providers in certain ZIP Codes that may be convenient to where you live or work. In some cases, these sources can help you identify physicians who speak languages other than English and give you detailed directions from your home or workplace to the provider's location.

11. 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.

12. 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 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 Primary Care Physician's name and telephone number.

13. 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. 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 complete details about the plan including benefits, limitations and exclusions.

14. 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:

  • Copayment - the amount a member pays for each in-network physician home or office visit. Physician copayments are for in-network care only. Network physicians agree to accept the copayment and UniCare's reimbursement as payment-in-full for covered services if the plan pays 100% of the covered charge. If the Schedule of Benefits states that the plans pays less than 100% for physician office visits, the member may have additional out-of-pocket costs.

This is only a brief summary of the plan. Please refer to the Certificate of Coverage for complete details about the plan including benefits, limitations and exclusions.

15. 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 (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?

16. 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 provider in plenty of time if he/she must cancel.

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Approvals and Referrals

17. 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 specialty treatment with their PCP. When specialty care is needed, the PCP will refer members to a specialist.

18. 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 women'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.

19. 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 Primary Care Physician.

20. What if the member needs inpatient hospital care?

If the member needs to be hospitalized, the Primary Care Physician will arrange for admission to a network hospital. The Primary Care Physician will also continue to be responsible for overseeing care.

The hospitalization in most instances must be referred by the 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 complete details about the plan including benefits, limitations and exclusions.

21. Do any other services require pre-certification?

The plan Certificate of Coverage 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.

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Emergency Care

22. What qualifies as an Emergency?

The definition of "emergency" is found in the Certificate of Coverage.

Emergency usually means medical care and treatment required to treat a medical condition of sudden onset or deterioration. It must be expected that failure to obtain immediate care could place the patient's life in danger or lead to serious physical impairment.

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 detailed information about the plan including benefits, conditions, limitations and exclusions.

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

If a sickness or injury is life-threatening or severe and immediate medical attention is required, 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 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 Primary Care Physician will be able to coordinate any further care.

24. Do you cover emergency care?

Members and their families have coverage for medical emergencies both in and outside of the UniCare HMO service area.

In life-threatening or severe 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 Primary Care Physician's office first; the phone number is on the member ID card. The 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 life-threatening or severe emergencies, the member should always go to the emergency room.

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Disabled Employees

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

UniCare's policies allow between one to six months of medical leave of absence and one to four months of personal leave of absence. The allotted time is selected by the group and agreed to by UniCare at the time the group is underwritten.

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Coverage/Benefits

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

Yes. The employer receives a supply of Certificates of Coverage to issue to employees enrolled in the plan.

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

Neither the UniCare Illinois HMO nor the UniCare Texas HMO have pre-existing restrictions.

28. Do you issue policies to minors?

We issue policies to the employer, not to individuals.

29. When does coverage begin?

After we receive a fully completed application, it may be:

  • The first day of the month following completion of the waiting period (Initial Enrollment Period);
  • The first day of the month following completion of a qualifying event (Special Enrollment Period);
  • The date of birth for a newborn; or
  • The date of adoption or placement in home for adoption

Effective dates are determined as follows:

  • If the fully completed application is received by UniCare prior to the completion of the employer's waiting period, the effective date will be the first day of the month following approval and expiration of the waiting period;
  • If the fully completed application is received by UniCare after the eligibility date, but within 30 days of becoming eligible, the effective date becomes the first of the month following approval of the application; and
  • If the application is received by UniCare more than 30 days after the employee's eligibility date, the applicant may be considered a late enrollee by definition under HIPAA, and the effective date may be delayed up to one year from the date of application for enrollment

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

HealthyExtensionsSM is a personal path toward creating a healthier lifestyle. UniCare believes there are many components to a member's health and well-being. HealthyExtensionsSM 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:

  • fitness club memberships
  • health and wellness products
  • weight loss programs
  • nutritional supplements
  • skin care products
  • parenting advice
  • prescription eyewear
  • laser vision correction
  • hearing aids
  • alternative health care information
  • massage therapy
  • and much more!

UniCare'S MedCall® hotline 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 assist with any health care questions any time, day or night. This service includes an audio library with over 200 audio tapes covering a wide range of health topics.

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, legal issues, 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 diabetes complications and in maintaining the good health of our members.

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

With UniCare HMO members have coverage for emergency care.

If a member has an urgent problem when he/she is away form 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 UniCare HMO and, to make it easier to assure that any bill for covered services is paid promptly, the member should call the customer service number listed on their ID card 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.

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.

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Enrollment and Renewals

32.What documentation is necessary for enrolling a group?

The following are guidelines for required documentation when submitting new business:

  • A copy of the agent's quite (based on final enrollment)
  • Small Group Employer Application (Master Application)
  • Applications from all enrolling employees/dependents
  • Applications from all employees/dependents declining coverage (sections 2&4 of the Employee Application must be completed)
  • Copy of the company's most recent State Employer's Quarterly Report (provide current employment status for all employees listed)
  • If this is a takeover submission, a copy of the last month's group premium statement
  • COBRA/FMLA Questionnaire (if applicable)
  • A company check for the first months medical, dental and life premium payable to UniCare Life & Health Insurance Company or UniCare Health Insurance Company of the Midwest
  • Submit 100% of the premium with the applications

33. 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 the group. Premium payment is acceptance of a group's renewal.

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

UniCare assigns effective dates as either the 1st or 15th of the month. The enrollment deadlines are as follows:

  • 1st effective date = 5th day of the month; or
  • 15th effective date = 12th day of the month

35. How do I submit enrollment files to the plan?

You may submit enrollment applications to us by mail or fax.

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

Not at this time.

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Eligibility

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

UniCare determines eligibility based on the information provided on the application. Standard processing once a completed enrollment application is received is 3 days turnaround time.

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Notification of Changes

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

An address change for your firm or employees shall be made in writing. Only the authorized representative of the group or the employee, respectively, can initiate an address change. Notification of employee address changes can be submitted via the Small Group Employee Information Change Form or a letter from the employee. Notification of employer address changes must be submitted on company letterhead, and be signed by an officer of the company. Please note that address changes may impact the available plan selection and current rates. It is important that UniCare be notified of address changes in a timely fashion.

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

You may submit a written request to change your elected waiting periods during open enrollment. The new waiting period would apply to new employees hired on or after the effective date of the change.

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

The length of the waiting period may be one, two or three calendar months, as selected by the group and agreed to by UniCare.

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COBRA

41. Does COBRA coverage count as creditable coverage?

Yes, COBRA counts as creditable coverage.

42. Do I have to offer COBRA to terminating employees or their dependents?

As mandated by Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), the federal law that requires employers with more than 20 employees to extend group health insurance coverage, you must offer COBRA to terminating employees. You should confer with your own legal counsel about specific questions you may have on COBRA.

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HIPAA

43. Who is eligible for HIPAA?

The provisions of the Health Insurance Portability and Accountability Act (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.

44. 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 by a new health carrier. Coverage prior to a 63-day break is not credited against a preexisting condition exclusion period by a new carrier.

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 an employer's plan requests information from an individual's prior plan regarding any of the categories of benefits under the alternative method, the individual's former plan must provide such information.

45. 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.

46. 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). 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.

47. 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.

48. 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 who was formerly covered under one of their plans 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.

49. 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

50. Is payment required at the time of application?

Yes, 100% of the premium should be submitted with all applications.

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

For a Small Group quote, you may contact a licensed UniCare agent or call 1(877) UniCare.

52. How do I obtain a large group quote?

To obtain a Large Group quote, call your broker or consultant or call 1(877) UniCare for a sales representative near you.

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

Employers have the flexibility to choose their preferred approach for contributing toward employee health premium. Employers must contribute either:

  • A minimum of 50% of the employees monthly health premium (Traditional Contribution);
  • &100 per employee per month or the employees actual premium for the month (whichever is less) for employee's health premium (Defined Contribution 100);
  • &80 per employee per month or the employee's actual premium for the month (whichever is less) for employee's health premium (Defined Contribution 80); or
  • Any fixed dollar amount selected by the employer greater than &100 per employee per month (increases available in &5 increments) or the employee's actual premium for the month (whichever is less) for employee's health premium (Defined Contribution Select)

54. Can a small group get lower rates if they do not use a broker?

No. Broker commissions are paid by the insurance carrier and do not affect the rate. For a more information on UniCare Small Group plans, please call 1(877) UniCare.

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Claims

55. 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.

56. What should my employee do if a claim is denied?

If a claim is denied in whole or in part, the member will receive a written notice of the denial. The notice will explain the reason for the denial. The member may request a review of the denied claim. The member must include reasons for requesting review.

57. 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 complete details about the plan including benefits, limitations and exclusions.

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