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. 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
• 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 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. 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 wherever they are purchased. 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?

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.
• 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 the members' choice as to whether the pharmacy accepts UniCare. It will help if the member shows the pharmacy the member 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 you to use quality, affordable prescription medications that are proven to be effective. If your plan does include a formulary, the member may pay a lower copayment when your 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 the most 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 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?

UniCare's Small Group plans include prescription drug coverage.

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Provider Network

6. Describe your provider networks.

MEDICAL: UniCare's Platinum PPO network 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. All network providers are carefully screened and must meet and maintain high standards of quality. 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: UniCare'S Pharmacy Network, the largest carrier owned PBM in the nation, administered through WellPoint Pharmacy Management, covers more than 52,000 pharmacies which is approximately 85% of all pharmacies nationwide. Our Pharmacy Network includes independent and chain pharmacies to give members the widest access with competitive reimbursement rates.

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

Directories are updated annually. Provider information is also 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.

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ID Cards

8. 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 and logo of the member's provider network is displayed in 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.

9. 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.

10. 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; usually the subscriber's Social Security number will be on all cards.

11. What if the member loses the 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

12. 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 Directory; and
• UniCare's Customer Service, which can be reached at the toll-free number on the 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.

13. What if a provider the 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.

The member has the option to choose an out-of-network provider, however, the out-of-pocket expense will be significantly higher.

14. What if a member's provider has left the network since the Provider Finder was last updated or the directory was last printed?

The status of payment (in or out-of-network) will be determined at the time the claim is paid. To ensure that the UniCare member receives in-network benefits, the member should always ask the provider's office staff to confirm when the member makes the first appointment that the provider is still in the network noted on the identification card.

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

When members choose to receive care from hospitals and physicians in a network affiliated with their UniCare PPO plan, they pay less out-of-pocket (sometimes only a small copayment for each visit) 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 will be higher, including deductible, coinsurance, and possibly balance billing. 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.

16. 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.

17. What if a network provider isn't available to treat a condition?

Generally, the in-network level of benefits is available only when a network provider is used. However, if a certain service is required and there is not an appropriate network specialist within reasonable driving distance (as defined in the Certificate of Coverage), the member can request an out-of-network referral if out-of-network referrals are permitted by the plan of benefits. Such a referral must be approved by the network through the UniCare Utilization Review process prior to services being rendered.

For more information, the member should call Customer Service at the number on their ID card.

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.

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 fully 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.

20. What are the out-of-pocket costs that a member may have to pay?

The benefit summary in your plan booklet specifies the amounts and the types of out-of-pocket charges for covered services. Depending on the service and whether the provider is in-network or out-of-network, the UniCare member may have to pay:

• Copayment - the amount the member pays for each physician home or office visit. Network physicians agree to accept the member's 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 plan pays less than 100% for physician office visits, the member may have additional out-of-pocket costs.
• Deductible - the amount the member or covered family member must pay annually before UniCare begins to pay for covered services other than in-network physician visits. Copayments do not count towards the annual deductible. The Schedule of Benefits states the amount of the deductible and whether it exists for both in-network services and out-of-network services, or out-of-network services only.
• Coinsurance -the percentage of the covered charge the member pays out-of-pocket after any deductible or copayment. The percentage of the coinsurance amount for i n-network care is usually lower than the percentage of coinsurance for out-of-network care.
• Out-of-Pocket Limit - To protect the member from high medical expenses, the plan may limit the amount the member must pay out-of-pocket each year for all covered services. Once the member reaches the out-of-pocket limit, the plan pays 100% of covered charges for the rest of the calendar year, subject to the terms and conditions of the plan. Depending on the plan, deductible and coinsurance payments for certain kinds of expenses may not apply toward the out-of-pocket limit. The member should refer to his/her plan booklet for out-of-pocket limit and charges to which the out-of-pocket limit does not apply.
• Reasonable and Customary Charge - the amount, determined by UniCare, that most providers in the member's area charge for the same service or procedure in the same setting (office or hospital). Out-of-network deductibles and coinsurance apply only to the provider's charge, or UniCare's reasonable and customary charge, whichever is less.
• Balance Bill - The amount a provider may bill the member if the charge for care is greater that UniCare's reasonable and customary charge. UniCare does not cover this amount, nor will it count toward any plan maximums. Network providers never balance bill for covered services. They always accept as payment-in-full the total of any copayment, deductible and coinsurance that the member pays and the network reimbursement that UniCare pays.

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. 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?

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.

22. What if a member cannot keep his/her appointment?

UniCare health plans do 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

23. 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 will keep out-of-pocket expenses to a minimum. If requested, network physicians can usually help refer the member to another provider in the network. In some cases, especially if a personal physician is out-of-network, the member may have to ask for a referral to a network specialist whom he/she has chosen.

24. 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 will pay the least out-of-pocket if they select a network hospital.

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

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Emergency Care

26. What qualifies as an Emergency?

The definition of "emergency" care 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. When used for treating routine ailments, they represent the most expensive and wasteful health care option. Go to the emergency room only for true emergencies, not for routine ailments or for convenience.

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

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

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

28. Do you cover emergency care?

UniCare covers emergency care wherever and whenever our members need it - 24 hours a day, seven days a week. If faced with a life-threatening 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.

In life-threatening or severe emergencies, the member should always go directly to the nearest emergency facility or call 911.

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Disabled Employees

29. 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

30. 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.

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

Pre-existing means a condition, regardless of its cause, for which medical advice, diagnosis, care or treatment was received or recommended during a 6-month period immediately preceding the earlier of (a) the effective date of coverage or (b) the first day of the waiting period. Pregnancy is not a preexisting condition for the purposes of a Small Group plan and genetic information is not a preexisting condition for the purposes of a Small Group plan unless there has been a diagnosis of the condition related to the information. Effective date of coverage is the first day on which coverage under the Certificate begins. Expenses due to a pre-existing condition are covered only if the expense is incurred after 12 consecutive months beginning on the earlier of (a) the effective date of coverage or (b) the first day of the waiting period. Any time limits of the pre-existing condition exclusion will be reduced by the number of days a covered person was covered under a "Qualifying Prior Coverage."

32. 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. HealthyExtensions 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.

33. 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.

In addition, UniCare's Platinum PPO members, can receive in-network benefits from any provider in UniCare's Platinum network all across the country. To access Platinum 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 are not part of the Platinum PPO.

34. Does UniCare issue policies to minors?

We issue policies to the employer, not individuals.

35. 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;
• 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.

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Enrollment and Renewals

36. 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

37. 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.

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

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

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

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

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

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

Not at this time.

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Eligibility

41. 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

42. 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.

43. 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.

44. 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

45. Does COBRA coverage count as creditable coverage?

Yes, COBRA counts as creditable coverage.

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

Yes, 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

47. 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.

48. 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.

49. 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.

50. 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.

51. 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.

52. 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.

53. 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

54. Is payment required at the time of application?

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

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

For a more information on UniCare Small Group plans, you may contact a licensed UniCare agent or call 1(877) UniCare.

56. How do I obtain a Large Group (51+ employees) quote?

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

57. 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)

58. 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

59. 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.

60. 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.

61. 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. Claims for non-network services should be filed as soon as possible, but no longer than 15 months after services are rendered. 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 complete details about the plan including benefits, limitations and exclusions.

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