United HealthCare Insurance Company UnitedHealthcare ...

1 UnitedHealthCareInsuranceCompanyUnitedHe althcareChoicePlusCertificateofCoverage, Riders,Amendments,andNoticesforPROGRESSI VEMEDICALASSOCIATESG roupNumber:GA9N4223 BWHealthPlan:S1- EPrescriptionCode:2 VEffectiveDate:January1,2012 OfferedandUnderwrittenbyUnitedHealthCare InsuranceCompanyRiders,Amendments, ,Connecticut06103-34081-800-357-1371 CertificateofCoveragePreexistingConditio nPleasenotethatyourPolicycontainsa ,see(Section2:Whatis NotCovered:Exclusions) ("Policy")isenteredintobyandbetweenUnite dHealthCareInsuranceCompanyandthe"Enroll ingGroup,"asdescribedin (post-Emergency)treatmentbegins.(Youdono thavetonotifyusbeforetheinitialEmergency treatment.)If youfailtonotifyusasrequired,Benefitswill bereducedto50% ,pleaserefertoArticle5:PolicyTermination AboutthisPolicyWhenweusethewords"we,""us ,"and"our"inthisdocument, ,X-RayandDiagnostics- ,X-RayandMajorDiagnostics- CT,PETS cans,MRI,andNuclearMedicine- sOfficeServices- BoneorJointoftheJaw, :ExclusionsandLimitationsHowWeUseHeading sin.

2 HowtoFilea ClaimIf YouReceiveCoveredHealthServicesfroma (Pre-service) (Post-Service) (Clinical) (BenefitGrievances) PartofPolicyThisCertificateofCoverage(Ce rtificate)is partofthePolicythatis a legaldocumentbetweenUnitedHealthCareInsu ranceCompanyandtheEnrollingGrouptoprovid eBenefitstoCoveredPersons,subjecttothete rms,conditions, newCertificate, ,interpret,modify,withdraworaddBenefits, ortoterminatethePolicy,aspermittedbylaw, turnbeoverruledbyanyCertificateweissueto youin :00midnightinthetimezoneoftheEnrollingGr oup , governedbyERISA unlesstheEnrollingGroupis , ,aswellasyourrightsandresponsibilities, :CoveredHealthServicesandSection2 Benefitsandanyattachmentsin a thereisa conflictbetweenthisCertificateandanysumm ariesprovidedtoyoubytheEnrollingGroup, partofa legaldocument, :DefinedTermsasyoureadthisdocumenttohave a "we,""us,"and"our"inthisdocument, "you"and"your,"wearereferringtopeoplewho areCoveredPersons,asthattermis definedinSection9: questionorconcernregardingyourBenefits, ,andthecorrespondingdatesthatcoveragebeg ins,arelistedinSection3 ,bothofthefollowingapply.

3 YourenrollmentmustbeinaccordancewiththeP olicyissuedtoyourEnrollingGroup, SubscriberorhisorherDependentasthoseterm saredefinedinSection9 , youhavequestionsaboutthis, spaymentsforCoveredHealthServicesandanyo bligationthatyoumayhavetopayfora portionofthecostofthoseCoveredHealthServ icesis setforthin theScheduleof andfacilities licensesandothercredentials, , theScheduleof :ExclusionsandLimitationstobecomefamilia rwiththisBenefitplan (ID) youdonotshowyourIDcard,theprovidermayfai ltobillthecorrectentityfortheservicesdel ivered, non-Networkprovider, a formatthatcontainsalloftheinformationwer equire,asdescribedinSection5: HowtoFilea youhavepriorcoveragethat,asrequiredbysta telaw,extendsbenefitsfora particularconditionora disability, :InterpretBenefitsandtheotherterms,limit ationsandexclusionssetoutinthisCertifica te,theScheduleofBenefits, , , (ratherthanaflatdollarCopayment),wecalcu latetheCopaymentamountasfollows:ForNetwo rkProviders:Step1 :Finally, ,pleaseseethedefinitionforEligibilityExp ensesin :DeductiblehasbeensatisfiedOutpatientSur gerychargeis $1,200 Contractedrateis $900 Copaymentis 20%Youpay20%of$900=$180 Wepay$900- $180= $720 ForNon-NetworkProvidersNon-MedicalEmerge ncyorNotCoordinatedbyUs:Step1 :Wedetermineif thereis :ActualOutpatientSurgerychargeis $1,500.

4 $1,200 Copaymentis 20%of $1,200(EligibleExpense)=$240 Wepay$1,200(EligibleExpense)- $240(Copayment)=$960 Youpaythedifferencebetweentheactualcharg esandEligibleExpensesandyourCopaymentamo unt:$1,500- $1,200= $300plus$240= $540 ForNon-NetworkProvidersEmergencyMedicalC onditionorOtherwiseCoordinatedbyUs:Step1 :Weworkwiththeprovidertoobtaina :If a negotiatedrateis obtained, a negotiatedrateisnotobtained,wecalculatey ourCopaymentbasedontheprovider :If a negotiatedrateis obtained, a negotiatedrateis notobtained,wecalculateourpaymentbysubtr actingyourCopaymentamountfromtheprovider :ActualOutpatientSurgerychargeis $1,500; $1,200 Copaymentis 20%Youpay$240 Wepay$1,200(negotiatedrate)- $240(Copayment)=$ $1,500 Copaymentis 20%Youpay$300 Wepay$1,500(Non-Negotiatedrate)-$300(Cop ayment)= $1,200 PayforOurPortionoftheCostofCoveredHealth ServicesWepayBenefitsforCoveredHealthSer vicesasdescribedinSection1:CoveredHealth ServicesandintheScheduleofBenefits,unles stheserviceis excludedinSection2 alsomeansthatnotallofthehealthcareservic esyoureceivemaybepaidfor(infullorin part) is ,youdonothavetosubmita.

5 Howto Filea networkproviderandthenetworkprovideris notableandnotavailabletomeetyourhealthca reneedswithoutunreasonabledelay,youmayse ekout-of-networkCoveredHealthServicesfro ma non-networkproviderandtheserviceswillber eimbursedasthoughtheywereprovidedbya ,inoursolediscretion,inaccordancewithone ormoreofthefollowingmethodologies:Asindi catedinthemostrecenteditionoftheCurrentP roceduralTerminology(CPT),a publicationoftheAmericanMedicalAssociati on,and/ortheCentersforMedicareandMedicai dServices(CMS). ( ,error,abuseandfraudreviews), (asmaybemodifiedbyourreimbursementpolici es) ,non-Networkprovidersarenotsubjecttothis prohibition,andmaybillyouforanyamountswe donotpay,includingamountsthataredeniedbe causeoneofourreimbursementpoliciesdoesno treimburse(inwholeorinpart) ,wemayprovideyouwithaccesstoinformationa boutadditionalservicesthatareavailableto you,suchasdiseasemanagementprograms,heal theducation, is solelyyourdecisionwhethertoparticipatein theprograms, :CoveredHealthServicesBenefitsforCovered HealthServicesBenefitsareavailableonlyif allofthefollowingaretrue:CoveredHealthSe rvicesarereceivedwhilethePolicyis a CoveredPersonandmeetsalleligibilityrequi rementsspecifiedin :TheamountyoumustpayfortheseCoveredHealt hServices(includinganyAnnualDeductible,C opaymentand/orCoinsurance).

6 AnylimitthatappliestotheseCoveredHealthS ervices(includingvisit,dayanddollarlimit sonservicesand/oranyMaximumPolicyBenefit ).Anylimitthatappliestotheamountyouarere quiredtopayina year(Out-of-Pocket Maximum). ,whenwesay"thisincludes,"it is listofservicesorexamples,westatespecific allythatthelist"islimitedto." licensedambulanceservice(eithergroundora irambulance,aswedetermineappropriate)bet weenfacilitieswhenthetransportis anyofthefollowing:Froma non-NetworkHospitaltoa Hospitalthatprovidesa (CHD)surgerieswhichareorderedbya ,butarenotlimitedto,surgeriestotreatcond itionssuchascoarctationoftheaorta,aortic stenosis,tetralogyoffallot,transposition ofthegreatvessels, AccidentOnlyDentalserviceswhenallofthefo llowingaretrue:Treatmentis severeenoughthatinitialcontactwitha Physicianordentistoccurredwithin72hourso ftheaccident.

7 (Youmayrequestanextensionofthistimeperio dprovidedthatyoudosowithin60daysoftheInj uryandif extenuatingcircumstancesexistduetothesev erityoftheInjury.)Pleasenotethatdentalda magethatoccursasa resultofnormalactivitiesofdailylivingore xtraordinaryuseoftheteethis :Treatmentisstartedwithinthreemonthsofth eaccident,unlessextenuatingcircumstances exist(suchasprolongedhospitalizationorth epresenceoffixationwiresfromfracturecare ). (rootcanal) (fillings). , , ,educationandmedicalnutritiontherapyserv icesmustbeorderedbya (dilatedretinalexaminations) , ,insulinsyringeswithneedles,bloodglucose andurineteststrips, :Orderedorprovidedbya Physicianforoutpatientuseprimarilyin a personin theabsenceofa morethanonepieceofDurableMedicalEquipmen tcanmeetyourfunctionalneeds, yourentorpurchasea pieceofDurableMedicalEquipmentthatexceed sthisguideline,youwillberesponsibleforan ycostdifferencebetweenthepieceyourentorp urchaseandthepiecewehavedeterminedis :Equipmenttoassistmobility,suchasa (includingtubing,connectorsandmasks).

8 Deliverypumpsfortubefeedings(includingtu bingandconnectors).Braces, bodypartareorthoticdevices, (exceptthatair-conditioners,humidifiers, dehumidifiers,airpurifiersandfilters,and personalcomfortitemsareexcludedfromcover age). ,appliance,pump,machine,stimulator, ,exceptthat:Benefitsforrepairandreplacem entdonotapplytodamageduetomisuse, , (ratherthanbeingadmittedtoa HospitalforanInpatientStay).Benefitsunde rthissectionarenotavailableforservicesto treata HomeHealthAgencythatarebothofthefollowin g:Orderedbya registerednurse,orprovidedbyeithera homehealthaideorlicensedpracticalnursean dsupervisedbya part-time,IntermittentCarescheduleandwhe nskilledcareis skillednursing,skilledteaching,andskille drehabilitationserviceswhenallofthefollo wingaretrue:It mustbedeliveredorsupervisedbylicensedtec hnicalorprofessionalmedicalpersonnelinor dertoobtainthespecifiedmedicaloutcome, is orderedbya isnotdeliveredforthepurposeofassistingwi thactivitiesofdailyliving,includingbutno tlimitedtodressing,feeding,bathingortran sferringfroma bedtoa is servicewillnotbedeterminedtobe"skilled" recommendedbya ,psychological, receivedfroma InpatientStayServicesandsuppliesprovided duringanInpatientStayin a a Semi-privateRoom(aroomwithtwoormorebeds) .

9 Physicianservicesforanesthesiologists,Em ergencyroomPhysicians,consultingPhysicia ns,pathologistsandradiologists.(Benefits forotherPhysicianservicesaredescribedund erPhysicianFeesforSurgicalandMedicalServ ices.) ,X-RayandDiagnostics- OutpatientServicesforSicknessandInjury-r elateddiagnosticpurposes,receivedonanout patientbasisata HospitalorAlternateFacilityinclude,butar enotlimitedto: ,pathologistsandradiologists.(Benefitsfo rotherPhysicianservicesaredescribedunder PhysicianFeesforSurgicalandMedicalServic es.)Whentheseservicesareperformedina Physician soffice,BenefitsaredescribedunderPhysici an sOfficeServices- , ,X-RayandMajorDiagnostics- CT,PETS cans,MRI,MRAandNuclearMedicine-Outpatien tServicesforCTscans,PETscans,MRI,MRA,nuc learmedicine,andmajordiagnosticservicesr eceivedonanoutpatientbasisata HospitalorAlternateFacilityorin a Physician ,pathologistsandradiologists.

10 (BenefitsforotherPhysicianservicesaredes cribedunderPhysicianFeesforSurgicalandMe dicalServices.) InpatientandIntermediateMentalHealthandS ubstanceAbuseServicesreceivedonaninpatie ntorIntermediateCarebasisin a ,whowillauthorizetheservices, anInpatientStayis required,it is coveredona ,inpatientdaysmaybeconvertedtoIntermedia teCare(suchaspartialhospitalizationorint ensiveoutpatientprograms) equivalentto: (eithersoberlivingortransitionallivingar rangements). MentalHealthorSubstanceAbuseServicesprov iderareatthediscretionoftheMentalHealth/ SubstanceAbuseDesignee, OutpatientMentalHealthandSubstanceAbuseS ervicesreceivedonanoutpatientbasisina provider sofficeoratanAlternateFacility,including :Mentalhealth, ,familyandgrouptherapeuticservices(inclu dingintensiveoutpatienttherapy). , :Pouches, , ,filters,lubricants,tape,appliancecleane rs,adhesive,adhesiveremover, OutpatientPharmaceuticalProductsthatarea dministeredonanoutpatientbasisin a Hospital,AlternateFacility,Physician soffice,orin a CoveredPerson ,duetotheircharacteristics(asdeterminedb yus)