Transcription of UNICARE STATE INDEMNITY PLAN MEDICARE EXTENSION
1 SERIES 2 UNICARE STATE INDEMNITY PLAN MEDICARE EXTENSIONM ember Handbook for MEDICARE RetireesEffective July 1, 2018 MEDICARE EXTENSION Member Handbook (2018-2019) 6/20/2018 10:45 AM 53369 MAMENUNC Rev. 06/18 UNICARE STATE INDEMNITY PLAN MEDICARE EXTENSION MEMBER HANDBOOK For MEDICARE retirees Effective July 1, 2018 2 6/20/2018 10:45 AM MEDICARE EXTENSION Member Handbook (2018-2019) Disclosure when Plan Meets Minimum Standards This health plan meets the Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance. Please see additional information below. MASSACHUSETTS REQUIREMENT TO PURCHASE HEALTH INSURANCE: As of January 1, 2008, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement based on affordability or individual hardship.
2 For more information call the Connector at 877-MA-ENROLL or visit the Connector website ( ). This health plan meets the Minimum Creditable Coverage standards that became effective July 1, 2008 as part of the Massachusetts Health Care Reform Law. If you are covered under this plan, you will satisfy the statutory requirement that you have health insurance meeting these standards. THIS DISCLOSURE IS FOR THE MINIMUM CREDITABLE COVERAGE STANDARDS THAT ARE EFFECTIVE JANUARY 1, 2018. BECAUSE THESE STANDARDS MAY CHANGE, REVIEW YOUR HEALTH PLAN MATERIALS EACH YEAR TO DETERMINE WHETHER YOUR HEALTH PLAN MEETS THE LATEST STANDARDS. If you have questions about this notice, you may contact the Division of Insurance by calling 617-521-7794 or visiting its website at Interpreting and Translating Services If you need a language interpreter when you call UNICARE Member Services, a customer service representative will access a language line and connect you with an interpreter who will translate your conversation with the representative.
3 If you use a TTY machine, you can reach UNICARE by calling 711. Si necesita ayuda en espa ol para entender este documento, puede solicitarla sin costo adicional, llamando al n mero de servicio al cliente que aparece al dorso de su tarjeta de identificaci n o en el folleto de inscripci n. MEDICARE EXTENSION Member Handbook (2018-2019) 6/20/2018 10:45 AM 3 Who to Contact Questions about medical or behavioral health coverage UNICARE STATE INDEMNITY Plan Box 9016 Andover, MA 01810-0916 Member Services and preapprovals: 800-442-9300 / TTY: 711 (toll free) 7:30 to 6:00 (M-Th) 7:30 to 5:00 (F) Email: Website: If you call after business hours, you can leave a message. Member Services will return your call on the next business day. For questions about: Benefits for a medical service or procedure Benefits for mental health or substance use disorder services Status of a medical or behavioral health claim Finding a doctor, hospital or other health care provider These sections of this handbook: Part 1: Getting Started (pages 11-24) Part 2: Your Medical Benefits (pages 25-72) Part 3: Your Behavioral Health Benefits (pages 73-84) Part 4: Using Your Plan (pages 85-126) Questions about prescription drug coverage SilverScript Customer Service: 877-876-7214 / TTY: 711 (toll free) Website: For questions about: Benefits for a prescription drug Status of a prescription drug claim Where to get prescriptions filled Which drugs are covered Information from Part 5.
4 Your Prescription Drug Benefits (pages 127-137) For other questions, such as questions about premiums or participation in any Group Insurance Commission (GIC) programs, please contact the GIC. 4 6/20/2018 10:45 AM MEDICARE EXTENSION Member Handbook (2018-2019) Table of Contents Disclosure when Plan Meets Minimum Standards .. 2 Interpreting and Translating Services .. 2 Who to Contact .. 3 Part 1: Getting Started .. 11 What you need to know to start using your plan. Chapter 1: First things first .. 12 What this handbook covers .. 12 Do you have other health insurance? .. 14 About your ID card .. 15 Sometimes, you need to get preapproval .. 15 Connect with your WellMASS benefits for better health .. 15 Getting the most out of MEDICARE EXTENSION .. 16 Chapter 2: About costs and billing .. 17 What member costs are (out-of-pocket costs) .. 17 How member costs work.
5 17 About out-of-pocket maximums .. 17 About copays .. 18 About coinsurance .. 19 Costs for behavioral health services .. 19 How MEDICARE and MEDICARE EXTENSION work together .. 20 About allowed amounts and MEDICARE -approved amounts .. 20 About balance billing .. 21 How the providers you use can affect your costs .. 22 When to use MEDICARE suppliers .. 23 When to use UNICARE preferred vendors .. 24 Part 2: Your Medical Benefits .. 25 What your coverage is for medical services. These benefits are administered by the UNICARE STATE INDEMNITY Plan. Chapter 3: Getting preapproval for medical services .. 26 About preapproval .. 26 How to request preapproval .. 26 Table of Contents MEDICARE EXTENSION Member Handbook (2018-2019) 6/20/2018 10:45 AM 5 Information you need to provide .. 26 Medical services that need preapproval .. 26 Important points to remember.
6 27 Preapproval requirements for medical 27 Chapter 4: Summary of your costs for medical services .. 28 Chapter 5: Covered medical services .. 33 Allergy shots .. 33 Ambulances .. 33 Anesthesia .. 34 Autism spectrum disorders .. 34 Behavioral health services .. 34 Cardiac rehabilitation (rehab) 34 Chemotherapy .. 35 Chiropractic care .. 35 Circumcision .. 36 Cleft lip and cleft palate .. 36 Clinical trials (clinical research studies) .. 36 Dental services .. 38 Diabetes care .. 39 Diabetic supplies .. 40 Dialysis .. 41 Doctor and other medical provider services .. 41 Durable medical equipment (DME) .. 42 Early intervention programs .. 43 Emergency care / urgent care .. 43 Enteral therapy .. 45 Eye care .. 46 Eyeglasses and contact lenses .. 46 Family planning .. 47 Fitness club reimbursement .. 47 Foot care (routine) .. 48 Gynecology exams .. 48 Hearing aids.
7 49 Hearing exams .. 49 Home health care .. 49 Home infusion therapy .. 51 Hospice and end-of-life care .. 51 Hospital admissions (inpatient) .. 53 Immunizations (vaccines) .. 55 Infertility treatment .. 55 Laboratory services (lab work) and radiology .. 56 Long-term care facilities .. 57 Table of Contents 6 6/20/2018 10:45 AM MEDICARE EXTENSION Member Handbook (2018-2019) Maternity services .. 57 Medical services (if not listed elsewhere) .. 57 Neuropsychological (neuropsych) testing .. 57 Occupational therapy .. 58 Outpatient hospital services (if not listed elsewhere) .. 58 Oxygen .. 58 Palliative care .. 59 Personal Emergency Response Systems (PERS) .. 59 Physical therapy .. 60 Prescription drugs .. 60 Preventive care .. 61 Private duty nursing .. 61 Prosthetics and orthotics .. 62 Radiation therapy .. 63 Rehabilitation (rehab) hospitals .. 63 Retail health clinics.
8 63 Skilled nursing facilities .. 63 Sleep studies .. 63 Speech therapy .. 64 Surgery .. 64 Tobacco cessation counseling .. 66 Transplants .. 66 Travel clinics .. 68 Urgent care .. 68 Walk-in clinics .. 68 Wigs .. 68 Chapter 6: Your benefits for preventive care .. 69 Part 3: Your Behavioral Health Benefits .. 73 What your coverage is for mental health and substance use disorder services. These benefits are administered by the UNICARE STATE INDEMNITY Plan. Chapter 7: Using your benefits for behavioral health .. 74 Coverage for behavioral health services .. 74 About behavioral health providers .. 74 Getting preapproval for behavioral health services .. 75 Chapter 8: Summary of your costs for behavioral health services .. 77 Chapter 9: Covered behavioral health services .. 78 Acute care (inpatient and outpatient) .. 78 Autism spectrum disorders .. 80 Table of Contents MEDICARE EXTENSION Member Handbook (2018-2019) 6/20/2018 10:45 AM 7 Emergency care.
9 81 Medication management (outpatient) .. 82 Methadone maintenance .. 82 Outpatient services .. 83 Substance use disorder assessment / referral .. 84 Therapy (outpatient) .. 84 Part 4: Using Your Plan .. 85 How to understand and use your plan and benefits. Chapter 10: Excluded and limited services .. 86 Chapter 11: About your plan and coverage .. 98 Types of health care providers .. 98 How to find providers .. 100 How UNICARE reimburses providers .. 100 How claims are processed .. 101 How to submit a claim .. 101 Deadlines for filing claims .. 102 About claim reviews .. 102 Deadlines on bringing legal action .. 102 Right of reimbursement (payment from a third party) .. 102 About your privacy rights .. 102 About the review process for preapprovals .. 103 About your appeal rights .. 104 Chapter 12: About enrollment and membership .. 105 Free or low-cost health coverage for children and families.
10 105 Application for coverage .. 105 When coverage begins .. 105 When coverage ends for enrollees .. 106 When coverage ends for dependents .. 106 Duplicate coverage .. 106 Special enrollment condition .. 106 Continuing coverage upon termination of employment .. 106 Group health continuation coverage under COBRA .. 108 Coordinating benefits with other health plans (COB) .. 112 Chapter 13: How to find out more .. 115 Getting help from UNICARE Member Services .. 115 About Mobile Health .. 116 Using the website .. 117 Using the 24/7 NurseLine .. 118 How to ask for a claim 118 Table of Contents 8 6/20/2018 10:45 AM MEDICARE EXTENSION Member Handbook (2018-2019) How to check on your claims .. 118 How to ask to have medical information released .. 118 Chapter 14: Plan definitions .. 119 Part 5: Your Prescription Drug Benefits .. 127 What your coverage is for prescription drugs.
