Medical Benefits Member Guide

Transcription

1 20 17 Medical Benefis Member Guide SEPTEMBER 1, 2016 AUGUST 31, 2017 THIS GUIDE IS FOR: Acive employees Reirees who are no eligible for Medicare (866)

2 Welcome Consumer Direced HealhSelec SM is he sae s high-deducible healh plan (HDHP) wih a healh savings accoun (HSA), available o Texas Employees Group Benefis Program (GBP) paricipans who are no eligible for Medicare. Key informaion for Plan Year 2017: UniedHealhcare adminisers he healh insurance porion of Consumer Direced HealhSelec. The Employees Reiremen Sysem of Texas (ERS) ses he benefis and pays he claims, while UniedHealhcare manages he provider nework, processes claims and provides cusomer service. Opum Bank, par of UniedHealhcare s financial services division, manages he HSA. Caremark will adminiser he Consumer Direced HealhSelec Prescripion Drug Program hrough December 31, As of January 1, 2017, OpumRx, an affiliae of UniedHealhcare, will become he hirdpary adminisraor of he prescripion drug program for Consumer Direced HealhSelec. Call he Cusomer Care Team oll-free a (866) (TTY 711), 8 a.m. 7 p.m. CT, Monday Friday and 7 a.m. 3 p.m. CT on Saurday. Creae your personal online accoun o find ou if a provider is in he nework, access personal informaion abou your accoun and learn abou oher programs from UniedHealhcare. To learn more abou Consumer Direced HealhSelec, visi Conens Your Plan Basics Wellness Programs and Services Key 2017 Benefis Online Resources Addiional Tips and Resources Key Terms...14 Please read his guide carefully. I will help you find wha you need, when you need i. For addiional informaion and resources menioned in his guide, visi Le s ge sared. 2

3 YOUR PLAN BASICS Ge off o a grea sar and learn he basics. How Consumer Direced HealhSelec Works Consumer Direced HealhSelec is made up of wo key pars: An HDHP, adminisered by UniedHealhcare, and An HSA program, adminisered by Opum Bank, a subsidiary of Unied HealhCare Services, Inc. To help cover he cos of he deducible and oher eligible ou-of-pocke healh care expenses, his plan allows you o open and conribue o a ax-advanaged HSA. You pay less when you say in he nework. While you can use any docor or hospial, ou-of-nework providers will charge you more. The UniedHealhcare provider nework includes more han 58,250 docors in Texas and 851,000 naionwide. To find a nework physician or hospial, go o and go o Find a Docor/Hospial. You do no need o choose a primary care physician (PCP) or ge referrals o see a specialis. Even hough i s no required, you will likely ge beer resuls when you work wih a PCP o help manage your care. Prevenive care is covered 100% when you use a nework provider even if he deducible has no been me. Prevenive Services Covered a 100% Prevenive care can help you say healhy. When you use a nework provider, you have many prevenive care benefis, including: Rouine checkups Screenings Immunizaions Prenaal care Well-woman visis Domesic violence screenings Conracepion approved by he Food and Drug Adminisraion Under he Affordable Care Ac (ACA), cerain prevenive healh and women s services are paid a 100% (a no cos o he paricipan) based on physician billing and diagnosis. In some cases, you may be responsible for paymen on cerain relaed services ha are no required o be paid a 100% by he ACA. Visi for prevenive care guidelines and a checklis o use wih your docor. 3

4 Your Go-o App for Healh The UniedHealhcare Healh4Me app for smarphones provides insan access o criical healh informaion. Wha Is an HSA? An HSA is similar o a regular bank accoun. When you open an HSA hrough Opum Bank, you ll receive a debi card you can use o pay for qualified medical expenses, including your deducible and coinsurance. To deposi money ino an HSA, you mus be covered under he Consumer Direced HealhSelec HDHP and mee oher eligibiliy rules, such as you are no enrolled in Medicare and you are no claimed as a dependen on someone else s ax reurns. To learn more abou eligibiliy rules, go o You own he money in your accoun, and you can make conribuions, up o IRS limis. The sae will also make a monhly conribuion o your HSA. Deailed insrucions on how o open your HSA will be sen o you afer annual enrollmen. Your savings grow ax-free. The balance accumulaes from year o year here is no use i or lose i rule. You can keep your HSA even if you change healh plans or change healh plans or employers. When you open an HSA wih Opum Bank, he Sae will conribue $45 per monh ($540 per year) for individual coverage and $90 per monh ($1,080 per year) for family coverage. You can make addiional conribuions hrough salary deducions (for acive employees only) or pos-ax conribuions o your accoun as well. Key feaures include he abiliy o: Search for nework physicians or faciliies View claims and benefi plan deails Check he saus of deducible and ou-of-pocke spending View your medical ID card Connec wih HealhSelec Cusomer Care View HSA balance Download Healh4Me from he App Sore or Google Play Healh4Me How he Plan Works wih Nework Providers Sep 1: Your deducible Sep 2: Your coinsurance Sep 3: Your ou-of-pocke maximum You pay he full cos unil you reach he deducible amoun ($2,100 individual/$4,200 family). You can use your HSA o help pay for qualified medical expenses. Pay wih your HSA or ou of pocke for nework expenses Individual: $2,100 Family: $4,200 Afer you reach your deducible amoun, you pay a porion of he coss. You can use your HSA o help pay your share. Plan pays 80% + You pay 20% coinsurance You can pay your share using your HSA. You will have differen deducible, coinsurance and ou-of-pocke limi amouns for non-nework care. * Toal ou-of-pocke maximum will increase o $6,550/Individual and $13,100/Family on 01/01/17. ** Prevenive care is covered a 100% when appropriaely coded as prevenive care per he Affordable Care Ac guidelines. 4 When you reach your ou-of-pocke maximum, your plan pays 100% of covered services for he res of he year. Plan covers 100% Individual: $6,450* Family: $12,900* Prevenive care is covered a 100% when you use a nework provider.** Please noe: Your deducible, coinsurance and ou-of-pocke max amouns will be much higher when you use non-nework providers.

5 RUN_DATE DATA_SEQ_NO CLIENT_NUMBER UHG_TYPE DOC_ID DOC_SEQ_ID NAME MAILSET_NUMBER CUSTCES_KEY _KEY0 CUSTCES_KEY2 CUSTCES_KEY3 CUSTCES_KEY4 CUSTCES_KEY5 CUSTCES_KEY6 CUSTCES_KEY7 CUSTCES_KEY8 CUSTCES_KEY DIG2SHRT HCAC/Medical ~00CARD ~00CARD :32: RT AC/Medical ~00CARD ~00CARD2 13:32:14 Always Carry Your Medical ID Card NO DIG2SHRT UMBER EY1 99_KEY0 EY2 EY3 EY4 EY5 EY6 EY7 EY8 EY HCAC/Medical ~00CARD ~00CARD :32:14 Your medical ID card has key informaion abou you and your coverage. Keep your card in your walle, your pockebook or your purse so you won forge i. DATE _SEQ_NO NT_NUMBER TYPE SEQ_ID SET_NUMBER CES_KEY _KEY0 CES_KEY2 CES_KEY3 CES_KEY4 CES_KEY5 CES_KEY6 CES_KEY7 CES_KEY8 CES_KEY DIG2SHRT HCAC/Medical ~00CARD ~00CARD :32:14 INTENTIONALLY BLANK INTENTIONALLY BLANK Show your medical ID card o your providers, so ha hey can updae INTENTIONALLY heir records BLANK and know how o bill for he services hey are providing o you. Need a Temporary Medical ID Card? If you los your medical ID card or are waiing o receive i in he mail, you can prin a emporary card o use unil you receive a permanen replacemen. Go o log ino your personal accoun and click Prin an ID Card. Remember, you can always view your medical ID card on he Healh4Me app for smarphones. Y BLANK You ll need hese numbers when you call o alk wih a TIONALLY cusomer BLANK care professional Prined: 08/01/16 INTENTIONALLY BLANK Healh Plan (80840) Healh Healh Plan Plan (80840) Member ID: Member ID: Group Number: Member ID: Group Number: Group Number: Member: This card does no guaranee coverage. To verify benefis, view claims, or find Member: Consumer Direced HealhSelec Member: a provider, This visicard he websies This doescard no or call. does guaranee no guaranee coverage. coverage. To verifytobenefis, Learn benefis, view claims, view abou claims, or find your or findcovered Consumer Direced Consumer HealhSelec Direced HealhSelec For Members: a provider, a provider, visi he websies visi he websies or call. or call. Payer ID Call his For number Members: For Members: o alk o a medical benefis Payer ID Payer ID Eff D cusomer care professional 99/99/9999 Prined: 08/01/16 For Providers: Prined: 08/01/ Find a nework docor or hospial Coinsurance: Eff D Eff D Medical Claims: PO BOX Alana, GA Prined: 08/01/16 80% (plan pays) 99/99/ /99/9999 For Providers: For Providers: in your Coinsurance: 80% area Deducibles: $2100 Ind $4200 Fam Medical Medical Claims: Claims: PO BOX PO BOX Alana, Alana, GA GA lan (80840) UniedHealhcare Choice Plus-HSA Group Look up healh and wellness r ID: Number: 0501 Adminisered by Unied HealhCare Services, Inc. Coinsurance: Group Number: Group 80% Number: Coinsurance: 80% r: Deducibles: $2100 Ind $4200 Fam This card does This This no card card guaranee does does no no guaranee coverage. coverage. To verify To To verify benefis, verify benefis, benefis, view viewclaims, claims, or or find find or find umer Deducibles: Direced$2100 HealhSelec Consumer Ind $4200 Direced Consumer Fam HealhSelec Direced HealhSelec a provider, visi he educaion resources UniedHealhcare a provider, visi a provider, Choice he websies visi he For Plus-HSA or websies call. or call. 0501Your cos for UniedHealhcare a ID Adminisered For Choice bymembers: For Unied Plus-HSA Members: HealhCare Services, Inc Payer ID 87726PayerAdminisered ID by Unied HealhCare Services, Inc. medical visi (wih Review news and updaes Eff D Eff D 99/99/9999 Shipper ID: Inser #1 Inser #2 99/99/9999 nework providers) For Providers: Shipping Mehod: DIRECT ForMedical Providers: Claims: PO BOX Inser #3 Alana, GA Inser #4 See Plan Year 2017 Maser CARRIER: USPS For Providers: Medicalwww.UniedHealhcareOnline.com Claims: PO BOX Inser #5 Alana, GA Inser #6 nce: 80% Address: Medical Claims: PO BOX Inser Alana, #7 GA Inser #8 Benefi Plan Documen (MBPD) s: $2100 Ind $4200 Fam Inser #9 Inser #10 0 Fam Shipper UniedHealhcare ID: Choice Plus-HSA Inser #11 Inser #1 Inser #12 Inser #2 Shipper Adminisered by Unied HealhCare Services, Inc. UniedHealhcare ID: Shipping Choice Mehod: Plus-HSA DIRECT Inser #1 Inser #3 Inser Inser #2 #4 Link o a member websie a Shipping AdminiseredMehod: by Unied HealhCare CARRIER: DIRECT Services, Inc. ealhcare Choice Plus-HSAUSPS CycleInser Dae: #3 Inser #5 Inser Inser #4 #6 d by Unied CARRIER: HealhCare Address: USPS Services, Inc. Visi his websie for PDFInser benefi Dae: Tue #5 Inser Aug 02, #7 13:32:14 Inser Inser #6 #8 Address: and wellness informaion MaxMover: Inser N#7 Inser #9 Inser Inser #8 #10 pper ID: Mailing/Meer Dae: Inser #1 UHGInser JOBInser ID: 5231 #9 Inser #2 GRP: # PV: 0443 RC: 0443Inser MKT: ŸŸŸŸŸ Inser #10 #12 pping Mehod: DIRECT Inser #3 MT: 50 Inser SA: 00#11 OI: #401 FORM: K20011 CPAY: B INTL ID: Inser #12 RRIER: 00000USPS Inser Inser #1 #5 DALE BROWN: Inser #6 NO#2LTR: TXERS2016 STOCK ID : STAN d: ress: DIRECT Inser Inser #3 #7 TEMPLATE: Inser Cycle NEW #8#4 Dae: FAMILY/IND : STD IND : 2SHRT : 2SHRT S Inser #9 Inser #10 Your Privae Online Inser #1Accoun Inser #5 Inser Cycle Inser #11 RSN CD: Inser #2 Dae: PDF #6Dae: Tue Aug 02, 13:32:14 Inser #12 Inser #3 Inser #7 Inser PDFInser Dae: #4 #8 MaxMover: Tue AugN02, Your healh 13:32:14 plan Quick access Inser #5 Inser #9 Inser Inser #6 #10 Cycle Dae: name and numbers o useful ools You Mailing/Meer can creae Dae: a personal accoun where you can see MaxMover: UHGN Inser #7 Inser #11 Inser Inser #8 #12JOB ID: 5231 GRP: PV: 0443 RC: 0443 MKT: ŸŸŸŸŸ PDF Dae: Tue Aug 02, 13:32:14 Mailing/Meer Dae: UHG JOB MT: ID: SA: 00 GRP: OI: FORM: PV: K CPAY: RC: 0443 B INTL MKT: ID: ŸŸŸŸŸ your own claims hisory Inser and #9 use MaxMover: various Nools. To se Inser up #10 Inser #11Cycle Dae: Inser MT: 50 #12SA: DALE 00BROWN: OI: 01 FORM: NO LTR: K20011 TXERS2016 CPAY: STOCK B INTL ID: : STAN ling/meer Dae: UHG JOB ID: 5231 GRP: PV: 0443 RC: 0443 MKT: ŸŸŸŸŸ your personal online accoun, PDF go MT: o Dae: 50 SA: Tue 00Aug OI: 01 02, FORM: 2016 DALE 13:32:14 CPAY: BROWN: TEMPLATE: B INTL ID: NO LTR: NEW FAMILY/IND TXERS2016: STOCK STD IND ID : 2SHRT : STAN: 2SHRT You will need informaion Cycle from Dae: MaxMover: your DALEmedical BROWN: N NOID LTR: card. TXERS2016 STOCK RSNID CD: : STAN TEMPLATE: NEW FAMILY/IND : STD IND : 2SHRT : 2SHRT ae: UHGTEMPLATE: JOB ID: 5231 NEWGRP: FAMILY/IND : STD PV: IND 0443 : 2SHRT RC: : SHRT PDF Dae: Tue Aug 02, 13:32:14 MKT: ŸŸŸŸŸ MT: RSN 50 SA: CD: 00 OI: 01 FORM: K20011 RSN CPAY: CD: B INTL ID: Once you regiser and MaxMover: log ino your N personal accoun a DALE BROWN: NO LTR: TXERS2016 STOCK ID : STAN UHG you JOB can: TEMPLATE: ID: 5231 GRP: NEW FAMILY/IND PV: : 0443 STD IND RC: : 2SHRT 0443 MKT: : 2SHRT ŸŸŸŸŸ MT: 50 SA: 00 OI: 01 FORM: K20011 CPAY: B INTL ID: RSN CD: Find ou if a provider DALE or hospial BROWN: NO is in LTR: he TXERS2016 nework STOCK ID : STAN TEMPLATE: NEW FAMILY/IND : STD IND : 2SHRT : 2SHRT View your claims and claims hisory RSN CD: Conac a Nurse Advocae Access healh and wellness informaion and programs, like Rally Ge healh and vision produc discouns Things You Can Do a Prined: 08/01/16 Prined: 08/01/16 healhselecofexas.com/cdhs Informaion abou new services Educaional websies Quick access o a nurse 5

6 WELLNESS PROGR AMS AND SERVICES Ge involved in your healh care decisions. Use hese complimenary ools and resources o help mainain and improve your healh. To learn more, call oll-free a (866) or go o Lose Weigh wih Real Appeal Real Appeal is an online weigh loss program ha can help you develop healhy habis o lose weigh and keep i off. Wheher you wan o drop a few pounds or make a more significan change, Real Appeal may be able o help you reach your weigh-loss goals and lead a healhier life. Real Appeal is available a no cos o eligible HealhSelec of Texas paricipans and dependens 18 and older (excludes Medicare primary paricipans) wih a body mass index (BMI) of 23 or higher. For more informaion or o enroll, visi healhselec.realappeal.com. Your Nurse Advocae: Ge Trused Informaion* Regisered nurses and maser s-level specialiss can help you anyime wih: Sympoms and reamen opions Docors and hospials Healh condiion managemen and more You can reach a regisered nurse oll-free a (866) simply say speak wih a nurse. Ge Suppor for a Chronic Condiion Nurse advocaes* can also provide resources for managing a chronic condiion. A chronic condiion may seem overwhelming and a imes hard o manage. To help you, we offer many Disease Managemen programs ha provide personalized suppor for he following condiions: Hear Failure Ashma Coronary Arery Disease (CAD) Chronic Obsrucive Pulmonary Disease (COPD) Diabees 6

7 Make an Informed Choice Abou Your Treamen Our Treamen Decision Suppor gives you access o specially rained regisered nurses* jus call oll-free a (866) and say speak wih a nurse. They can answer your quesions and help you make an informed choice abou your reamen opions for services relaed o hese condiions: Coronary disease Breas cancer Chronic back pain Benign uerine condiion Hip or knee replacemen Endomeriosis Benign prosae disease Fibroids Prosae cancer Enroll in a Healh Coaching Program* Our Wellness Coaching programs suppor individuals ineresed in: Diabees Sress Managemen Exercise Tobacco Cessaion Hear Healh Weigh Managemen Nuriion Save on Wellness and Vision Producs and Services Enjoy a healhy lifesyle for less, wih our discouned healh and vision producs and services. Ge discouns on finess club memberships, weigh loss programs, glasses, conac lenses, laser vision correcion and more. Access our healh discoun program** a Our wellness coaches are experienced wellness consulans. They can help you se your goals and creae a personalized plan o help you mee hem. Members ge assigned o one wellness coach a he beginning of heir program and keep he same coach hroughou heir program. If you are dealing wih more han one issue, you can enroll yourself in muliple programs and receive unlimied elephone coaching or informaion hrough he mail. We have mulilingual coaching, including Spanish-speaking coaches. To learn more, call oll-free a (866) Receive Personalized Guidance Throughou Your Pregnancy The Healhy Pregnancy program helps expecan mohers hrough every sage of pregnancy and delivery. The program offers 24-hour access o experienced nurses, he online Healhy Pregnancy Owner s Manual and oher maerials, as well as complimenary gifs (subjec o availabiliy). To enroll, call oll-free a (888) * This service should no be used for emergency or urgen care needs. In an emergency, call 911 or go o he neares emergency room. The informaion provided hrough he program is for informaional purposes only and provided as par of your healh plan. Wellness nurses, coaches and oher represenaives canno diagnose problems or recommend reamen and are no a subsiue for your docor s care. Your healh informaion is kep confidenial in accordance wih he law. The program is no an insurance program and may be disconinued a any ime. ** The healh discoun program is no insurance. 7

8 KEY 2017 BENEFITS Plan Overview Nework Consumer Direced HealhSelec Non-Nework Deducible (per paricipan/family) $2,100/$4,200 $4,200/$8,400 Coinsurance maximum (per paricipan) Inpaien copaymen maximum (per paricipan) None None None None TOTAL ANNUAL OUT-OF-POCKET MAXIMUM (per paricipan/family; includes copaymens for medical services and prescripion medicaions, deducibles and coinsurance) Effecive January 1, 2016: $6,450 per paricipan, $12,900 per family Effecive January 1, 2017: $6,550 per paricipan, $13,100 per family Lifeime maximum None None Primary care physician (PCP) required No No Effecive January 1, 2016: $12,900 per paricipan, $25,800 per family Effecive January 1, 2017: $13,100 per paricipan, $26,200 per family Plan Deails Nework Non-Nework PCP office visi Specialis office visi Rouine physicals* (including vision screenings for children) and well-woman exams* $0 40% coinsurance Virual visis 20% coinsurance No covered Convenience care clinic (no PCP referral required) Urgen care clinic (no PCP referral required) Eye exams Rouine exams are limied o one exam per year. Maerniy care* Physician charges only, including delivery fees; inpaien hospial benefi applies for he inpaien say (complicaions of pregnancy are reaed as any oher medical condiion) $0 for rouine prenaal obserical office visis 40% coinsurance Office surgery and diagnosic procedures Allergy anigens/serum Allergy injecions Allergy esing DME (Durable Medical Equipmen) (3-year replacemen limi) Prior Auhorizaion required for DME over $1,000. Diabeic Supplies 20% coinsurance 20% coinsurance * Under he Affordable Care Ac, cerain prevenive and women s healh services are paid a 100% (a no cos o he paricipan) based on physician billing and diagnosis. In some cases, you will sill be responsible for paymen on some services. 8

9 Plan Deails Nework Consumer Direced HealhSelec Non-Nework Diagnosic low-ech radiology X-rays Mammography Bone densiy scan Echocardiogram Ulrasound High-ech radiology CT scan MRI Nuclear medicine Prior Auhorizaion required. Chiropracic care (benefi maximum of $75 per visi and maximum 30 visis per calendar year, per paricipan) 20% coinsurance, plus amoun over benefi maximum 40% coinsurance, plus amoun over benefi maximum Inpaien hospial Prior Auhorizaion required. Inpaien physician (per admission) You may have o pay addiional coss if reaed by a non-nework physician during your hospial say. Emergency room In a non-emergency siuaion, consider less expensive opions, such as a virual visi, convenience care clinic or urgen care clinic. Oupaien day-surgery Faciliy (faciliy charges) Oupaien day-surgery Physician (physician charges) 20% coinsurance 20% coinsurance Hearing aids Plan pays up o $1,000 maximum benefi (per ear) for any consecuive hree-year (36-monh) period. 20% coinsurance (plus any amoun over he benefi maximum) 20% coinsurance (plus any amoun over he benefi maximum) Ambulance services (Prior Auhorizaion required for non-emergen air) 20% coinsurance 20% coinsurance Menal healh and subsance use disorder Inpaien hospial Prior Auhorizaion required. Oupaien faciliy care (parial hospializaion/day reamen and inensive oupaien reamen) Oupaien physician or menal healh provider services The chars on hese wo pages include ou-of-pocke coss for common services. For deailed informaion abou benefis, limiaions and exclusions, refer o he Maser Benefi Plan Documen (MBPD) under he Publicaions and Forms ab a on or afer Sepember 1,

10 ONLINE RESOURCES Use hese addiional complimenary resources o ge educaional informaion online a Virual Docor Visis Now you can see a docor wihou leaving your home or office wih he new virual docor visi benefi available o HealhSelec plan members and covered dependens. A virual visi is a convenien care opion when your docor is unavailable, when you become ill while raveling, or as an alernaive o he emergency room or urgen care for non-emergency healh issues. Here s how i works: You mus use nework providers for services o be covered. Mee wih a licensed virual visi nework provider from your compuer or mobile device using secure online audio and video echnology. Virual visi providers can diagnose and rea a wide range of medical condiions such as sinus problems, sore hroa, pink eye, bronchiis and more. Mos virual visis ake 10 o 15 minues and he service is available 24 hours a day, including weekends and holidays. A docor is generally available wihin 30 minues of your reques, or you can schedule an appoinmen. If needed, virual visi docors can wrie an elecronic prescripion for pick up a your local pharmacy. Prescripion services are currenly available in Texas bu may no be available in oher saes. Afer locaing and regisering wih a nework provider and requesing a visi, you pay your porion of he cos wih a credi or debi card. To locae a nework virual visi provider or for more informaion, log in o your personal online accoun a and click on he Virual Visis link. Nework Virual Visi Member Healh Cos Non-Nework 20% coinsurance No covered 10

11 Healh Care Lane Visi exas for informaion abou healh and wellness opics. Make sure o check ou Wellness Days, a fun-filled online fesival of good healh and wellness. Healhy Mind Healhy Body Newsleer Our award-winning Healhy Mind Healhy Body online publicaion provides he laes healh news and ips, and allows you o selec healh opics ha mee your personal needs and ineress. Topics range from family healh and finess, o diabees and ashma managemen. Sign up a Reach Your Healh Goals wih Rally Rally is a new ineracive healh experience on I can help you ge healhier one small sep a a ime. I shows you how o make simple changes o your daily rouine and moivaes you along he way. Take he Rally Healh Survey o ge an immediae, confidenial assessmen of your overall healh compared o your acual age called your Rally Age SM. Choose from recommended Missions simple hings you can do o improve your healh, such as focus on fruis and veggies or read for 20 minues. Sep up o a Rally Healh Challenge o help you reach your healh goals. Earn Rally Coins for your effors and use hem o conribue o seleced chariies. Your coins will be combined wih hose of oher Rally users o reach a cerain goal. When he goal is reached, Rally will make a moneary conribuion o ha organizaion. You can rack up Rally Coins for joining Missions, pushing yourself in a challenge and even jus for logging in each day. To ge sared, log ino your personal online accoun a 11

12 ADDITIONAL TIPS AND RESOURCES Learn more abou your care opions, Prior Auhorizaions and delivery opions for your healh documens. Where o Go When You Are Sick or Injured For mos medical problems, you should ry o go o your regular healh care provider firs. Bu if your docor is no available, he char below can help you choose he righ place for care for your siuaion. You can alk o a nurse o help you decide where o go for care call anyime oll-free a (866) (simply say speak wih a nurse ). Remember, in a rue emergency, i is always bes o call 911. Care cener Docor s Office Why would I use his care cener? You need rouine care or reamen for a curren healh issue. Your docor knows your healh hisory, can access your medical records, provide prevenive and rouine care, manage your medicaions and refer you o a specialis, if necessary. Wha ype of care would hey provide? 1 Rouine checkups Immunizaions Prevenive services Help you manage your general healh Wha are he cos and ime consideraions? 2 Ofen requires a copaymen and/or coinsurance Normally requires an appoinmen Scheduled appoinmens can help reduce wai ime Virual Visi Convenience Care Clinic 3 You wan a convenien way o speak wih a docor abou a non-urgen condiion wihou leaving your home or work place. A virual visi les you see and alk o a docor in he virual provider nework from your mobile device or compuer when you need non-emergency medical aenion. No appoinmen or referral is needed. You can ge o your docor s office, bu your condiion is no urgen or an emergency. Convenience care clinics are ypically locaed in many reail sores offering services for minor healh condiions. Saffed by nurse praciioners and physician assisans. Bladder infecion/ urinary rac infecion Bronchiis Cold/flu Diarrhea Fever Migraine/headaches Pink eye Rash Sinus problems Sore hroa Somachache Common infecions (for example, srep hroa) Minor skin condiions (for example, poison ivy) Flu shos Pregnancy ess Minor cus Earaches Ofen requires a copaymen and/or coinsurance ha is less han an office visi Virual visi providers are expeced o deliver care wihin 30 minues or less from he ime of he paien s reques Paiens can also make an appoinmen for anoher ime wih a virual visi docor Ofen requires a copaymen and/or coinsurance similar o office visi Walk-in paiens welcome wih no appoinmens necessary, bu wai imes can vary Urgen Care Cener 3 You may need care quickly, bu i is no an emergency, and your docor may no be available. Urgen care ceners offer reamen for non-life hreaening injuries or illnesses. Saffed by qualified physicians. Sprains Srains Minor broken bones (for example, a finger) Minor infecions Minor burns Ofen a less cosly alernaive o he emergency room Walk-in paiens welcome, bu waiing periods may be longer as paiens wih more urgen needs will be reaed firs Emergency Room (ER) You need immediae reamen of a very serious or criical condiion. The ER is for he reamen of life-hreaening or very serious condiions ha require immediae medical aenion. Do no ignore an emergency. If a siuaion seems life-hreaening, ake acion. Call 911 or your local emergency number righ away. Heavy bleeding Large open wounds Sudden change in vision Ches pain Sudden weakness or rouble alking Major burns Spinal injuries Severe head injury Difficuly breahing Major broken bones Requires a much higher copaymen and/or coinsurance Open 24/7, bu waiing periods may be long based on he number of paiens 1 This is a sample lis of services and may no be all-inclusive. 2 Coss and ime informaion represen averages only and are no ied o a specific condiion or reamen. Your ou-of-pocke coss will vary based on plan design. 3 Convenience Care Clinics and Urgen Care Ceners may no be available where you live. 12

13 Prior Auhorizaions for Cerain Healh Services Cerain healh services like inpaien hospial says, skilled nursing services, home healh services and durable medical equipmen over $1,000 mus be pre-auhorized. When you use a nework provider, ha provider will be responsible for obaining any Prior Auhorizaions required by he plan. Ongoing reamens including oupaien rehabiliaion herapies, such as physical herapy or occupaional herapy, durable medical equipmen and chiropracic reamen, mus be considered medically necessary and would require he provider o submi a reamen plan. Thank You for Going Green wih Us HealhSelec paricipans auomaically receive heir Explanaion of Benefis (EOB), healh saemens and claim leers online. An is sen o you when your documens are ready for viewing. Remember, an EOB is no a bill. Should you desire mail delivery, you can reques prined versions of hese documens jus call oll-free a (866) and ask o change your communicaion preferences from online o paper delivery. For illusraive purposes sample only 13

14 KEY TERMS Benefis: Medical iems and healh services ha are covered under he HealhSelec plan. Coinsurance: The percenage of he cos ha you have o pay for covered healh services afer you have paid any applicable deducibles and copaymens. Deducibles: The se dollar amoun ha you pay before he HealhSelec plan sars o pay for covered benefis, if applicable o your covered benefis. Healh saemen: A documen showing monhly claim aciviy and coss for all family members covered on your plan. I shows nework and non-nework informaion, as well as remaining balances for deducibles and ou-of-pocke coss. Maser Benefi Plan Documen (MBPD): A descripion of he benefis included in your plan. Medical ID card: The card issued o you by UniedHealhcare ha includes your name, group and policy informaion, and imporan phone numbers, such as Cusomer Care. Nework provider: Docors, hospials, nursing homes, laboraories and oher providers ha have conracs wih UniedHealhcare. Someimes called in-nework provider or paricipaing nework provider. You will pay more for services provided by non-nework providers. Non-nework provider: Docors, hospials and oher providers ha do no paricipae in he UniedHealhcare nework. Their services cos you more. Someimes called ou-of-nework provider or non-paricipaing nework provider. Ou-of-pocke coss: The coss for healh services ha are your responsibiliy. Ou-of-pocke maximum: The mos you have o pay for covered healh services during he calendar year. Ou-of-pocke maximum includes deducible, coinsurance and copaymens, if applicable. Primary care physician (PCP): This is he docor you go o firs when you are no feeling well. A PCP can be an Inernis, OB/Gyn, Family Docor or oher provider lised in he PCP secion of he Provider Direcory and online Provider Search Tool a To see a complee Glossary of Healh Coverage and Medical Terms, go o Publicaions and Forms ab. 14

15 TO LEARN MORE ABOUT YOUR BENEFITS, TOOLS AND RESOURCES: Visi your personal online accoun a or he HealhSelec websie a Call he HealhSelec Cusomer Care Team oll-free a (866) (TTY 711), 8 a.m. 7 p.m. CT, Monday Friday and 7 a.m. 3 p.m. CT on Saurday. Adminisraive services provided by Unied HealhCare Services, Inc. or heir affiliaes. Consumer Direced HealhSelec includes a high-deducible healh plan and healh savings accoun adminisered by UniedHealhcare and Opum Bank, boh subsidiaries of Unied HealhCare Services, Inc. Consumer Direced HealhSelec is a high-deducible healh plan (HDHP) wih a healh savings accoun (HSA) ha is designed o comply wih IRS requiremens and eligible enrollees may open a healh savings accoun (HSA) wih Opum Bank, Member of FDIC. The HSA refers only and specifically o he healh savings accoun ha is adminisered by Opum Bank, and no o he associaed HDHP. Healh savings accouns (HSAs) are individual accouns offered by Opum Bank, Member FDIC, and are subjec o eligibiliy and resricions, including bu no limied o resricions on disribuions for qualified medical expenses se forh in secion 213(d) of he Inernal Revenue Code. Sae axes may apply. Fees may reduce earnings on accoun. This communicaion is no inended as legal or ax advice. Please conac a compeen legal or ax professional for personal advice on eligibiliy, ax reamen and resricions. Federal and sae laws and regulaions are subjec o change. Real Appeal is a volunary weigh loss program ha is offered o eligible paricipans as par of heir benefi plan. The informaion provided under his program is for general informaional purposes only and is no inended o be nor should be consrued as medical and/or nuriional advice. Paricipans should consul an appropriae healh care professional o deermine wha may be righ for hem. Any iems/ools ha are provided may be axable and paricipans should consul an appropriae ax professional o deermine any ax obligaions hey may have from receiving iems/ools under he program. Rally Healh provides healh and well-being informaion and suppor as par of your healh plan. I does no provide medical advice or oher healh services, and is no a subsiue for your docor s care. If you have specific healh care needs, consul an appropriae healh care professional. Paricipaion in he healh survey is volunary. Your responses will be kep confidenial in accordance wih he law and will only be used o provide healh and wellness recommendaions or conduc oher plan aciviies. Virual visis are no an insurance produc, healh care provider or a healh plan. Unless oherwise required, benefis are available only when services are delivered hrough a Designaed Virual Nework Provider. Virual visis are no inended o address emergency or life-hreaening medical condiions and should no be used in hose circumsances. Services may no be available a all imes or in all locaions. Advocae services should no be used for emergency or urgen care needs. In an emergency, call 911 or go o he neares emergency room. The informaion provided hrough Advocae (Advocae4Me) services is for informaional purposes only and provided as par of your healh plan. Wellness nurses, coaches and oher represenaives canno diagnose problems or recommend reamen and are no a subsiue for your docor s care. Your healh informaion is kep confidenial in accordance wih he law. Advocae services are no an insurance program and may be disconinued a any ime. The informaion provided hrough hese programs is for educaional purposes only as a par of your healh plan and is no a subsiue for your docor s care. Please discuss wih your docor how he informaion provided is righ for you. Your personal healh informaion is kep privae in accordance wih your plan s privacy policy. The Healhy Pregnancy Program follows naional pracice sandards from he Insiue for Clinical Sysems Improvemen. The Healhy Pregnancy Program can no diagnose problems or recommend specific reamen. The informaion provided is no a subsiue for your docor s care. For a complee descripion of he UniedHealh Premium Designaion program, including deails on he mehodology used, geographic availabiliy, program limiaions and medical specialies paricipaing, please see myuhc.com/hs. Disease Managemen programs and services may vary on a locaion-by-locaion basis and are subjec o change wih wrien noice. UniedHealhcare does no guaranee availabiliy of programs in all service areas and provider paricipaion may vary. Cerain iems may be excluded from coverage and oher requiremens or resricions may apply. If you selec a new provider or are assigned o a provider who does no paricipae in he Disease Managemen program, your paricipaion in he program will be erminaed. Disclosure: The Healh Discoun Program is adminisered by HealhAllies, Inc., a discoun medical plan organizaion. The Healh Discoun Program is NOT insurance. The discoun program provides discouns a cerain healh care providers for medical services. The discoun program does no make paymens direcly o he providers of medical services. The discoun program member is obligaed o pay for all healh care services bu will receive a discoun from hose healh care providers who have conraced wih he discoun plan organizaion. HealhAllies, Inc., is locaed a P.O. Box 10340, Glendale, CA, 91209, , ohacusomercare@opumhealh.com. The healh discoun program is offered o exising members of cerain producs underwrien or provided by UniedHealhcare Insurance Company or is affiliaes o provide specific discouns and o encourage paricipaion in wellness programs. Healh care professional availabiliy for cerain services may be dependen on licensure, scope of pracice resricions or oher requiremens in he sae. UniedHealhcare does no endorse or guaranee healh producs/services available hrough he discoun program. This program may no be available in all saes or for all groups. Componens subjec o change. NOTE: ERS canno and does no guaranee he lengh of ime ha a specific or ype of value-added produc will be offered or ha a produc will be offered in he fuure. If you have quesions or concerns abou hese producs, please conac UniedHealhcare direcly. All rademarks are he propery of heir respecive owners. 15

16 KEY HEALTHSELECT CONTACT INFORMATION Consumer Direced HealhSelec Websie Personal Online Accoun Consumer Direced HealhSelec Cusomer Care (866) (TTY 711) 24/7 Nurse Access (866) (say speak wih a nurse ) Healhy Pregnancy (888) Prescripion Drug Program Caremark (hrough December 31, 2016) (888) HealhSelec Cusomer Care (beginning January 1, 2017) (866) (TTY 711) /16

17 UniedHealhcare Services, Inc., on behalf of iself and is affiliaed companies complies wih applicable Federal civil righs laws and does no discriminae on he basis of race, color, naional origin, age, disabiliy, or sex. UniedHealhcare does no exclude people or rea hem differenly because of race, color, naional origin, age, disabiliy, or sex. UniedHealhcare provides free aids and services o people wih disabiliies o communicae effecively wih us, such as: Qualified sign language inerpreers Wrien informaion in oher formas (large prin, audio, accessible elecronic formas, oher formas) Provides free language services o people whose primary language is no English, such as: Qualified inerpreers Informaion wrien in oher languages If you need hese services, please call oll-free , TTY 711, Monday hrough Friday, 8 a.m. o 7 p.m. CT and Saurday, 7 a.m. o 3 p.m. CT. If you believe ha he Company has failed o provide hese services or discriminaed in anoher way on he basis of race, color, naional origin, age, disabiliy, or sex, you can file a grievance in wriing by mail or . A grievance mus be sen wihin 60 calendar days of he dae ha you become aware of he discriminaory acion and conain he name and address of he person filing i along wih he problem and he requesed remedy. A wrien decision will be sen o you wihin 30 calendar days. If you disagree wih he decision, you may file an appeal wihin 15 calendar days of receiving he decision. Civil Righs Coordinaor P.O. Box Sal Lake Ciy, UT UHC_Civil_Righs@UHC.com If you need help filing a grievance, please call oll-free , TTY 711, Monday hrough Friday, 8 a.m. o 7 p.m. CT and Saurday, 7 a.m. o 3 p.m. CT. Your can also file a complain direcly wih he U.S. Dep. of Healh and Human services online, by phone or mail: Online hps://ocrporal.hhs.gov/ocr/poral/lobby.jsf Complain forms are available a hp:// Phone: Toll-free , (TDD) Mail: U.S. Dep. of Healh and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washingon, D.C

18 You have he righ o ge help and informaion in your language a no cos. To reques an inerpreer, please call oll-free , TTY 711, Monday hrough Friday, 8 a.m. o 7 p.m. CT and Saurday, 7 a.m. o 3 p.m. CT. This leer is also available in oher formas like large prin. To reques he documen in anoher forma, please call oll-free , TTY 711, Monday hrough Friday, 8 a.m. o 7 p.m. CT and Saurday, 7 a.m. o 3 p.m. CT. 1 Spanish Tiene derecho a recibir ayuda e información en su idioma sin coso. Para soliciar un inérpree, llame al número de eléfono grauio para miembros que se encuenra en su arjea de idenificación del plan de salud y presione TTY Vienamese Quý vị có quyền được giúp đỡ và cấp hông in bằng ngôn ngữ của quý vị miễn phí. Để yêu cầu được hông dịch viên giúp đỡ, vui lòng gọi số điện hoại miễn phí dành cho hội viên được nêu rên hẻ ID chương rình bảo hiểm y ế của quý vị, bấm số TTY Chinese 您有權利免費以您的母語得到幫助和訊息 洽詢一位翻譯員, 請撥打您 健保計劃會員卡上的免付費會員電話號碼, 再按 聽力語 言殘障服務專線 Korean 귀하는도움과정보를귀하의언어로비용부담없이얻을수있는권리가있습니다. 통역사를요청하기위해서는귀하의플랜 ID카드에기재된무료회원전화번호로전화하여 번을누르십시오. TTY Arabic لك الحق في الحصول على المساعدة والمعلومات بلغتك دون تحمل أي تكلفة. لطلب مترجم فوري اتصل برقم الھاتف المجاني الخاص بالا عضاء المدرج ببطاقة م عر ف العضویة الخاصة بخطتك الصحیة واضغط على الھاتف النصي (TTY) Urdu آپ کو اپنی زبان میں مفت مدد اور معلومات حاصل کرنے کا حق ہے کسی ترجمان سے بات کرنے کے لي ے ڻول فری ممبر فون نمبر پر کال کریں جو آپ کے ہیلتھ پلان آي ی ڈی کارڈ پر درج ہے دباي یں TTY Tagalog May karapaan kang makaanggap ng ulong a impormasyon sa iyong wika nang walang bayad. Upang humiling ng agasalin, awagan ang oll-free na numero ng elepono na nakalagay sa iyong ID card ng planong pangkalusugan, pinduin ang TTY French Vous avez le droi d'obenir grauiemen de l'aide e des renseignemens dans vore langue. Pour demander à parler à un inerprèe, appelez le numéro de éléphone sans frais figuran sur vore care d affilié du régime de soins de sané e appuyez sur la ouche ATS Hindi आप क प स अपन भ ष म सह यत एव ज नक र न:श ल क प र प त करन क अ धक र ह द भ षए क लए अन र ध करन क लए, अपन ह ल थ प ल न ID क डर पर स च बद ध ट ल-फ र न बर पर फ़ न कर, दब ए TTY 711

19 شما حق دارید کھ کمک و اطلاعات بھ زبان خود را بھ طور رایگان دریافت نمایید. برای 10 Persian درخواست مترجم شفاھی با شماره تلفن رایگان قید شده در کارت شناسایی برنامھ بھداشتی خود تماس حاصل نموده و را فشار دھید. TTY German Sie haben das Rech, kosenlose Hilfe und Informaionen in Ihrer Sprache zu erhalen. Um einen Dolmescher anzufordern, rufen Sie die gebührenfreie Nummer auf Ihrer Krankenversicherungskare an und drücken Sie die TTY Gujarai તમન વન લ ય મદદ અન તમ ર ભ ષ મ મ હત મ ળવવ ન અ ધક ર છ. ભ ષય મ ટ વન ત કરવ, તમ ર હ લ થ પ લ ન ID ક ડર પરન ચ મ આપ લ ટ લ-ફ ર મ મ બર ફ ન ન બર ઉપર ક લ કર, દબ વ. TTY Russian Вы имеете право на бесплатное получение помощи и информации на вашем языке. Чтобы подать запрос переводчика позвоните по бесплатному номеру телефона, указанному на обратной стороне вашей идентификационной карты и нажмите Линия TTY Japanese ご希望の言語でサポートを受けたり 情報を入手したりすることができます 料金はかかりません 通訳をご希望の場合は 医療プランの ID カードに記載されているメンバー用のフリーダイヤルまでお電話の上 を押してください TTY 専用番号は 711です 15 Laoian ທ ານມ ສດທ ຈະໄດ ຮ ບການຊ ວຍເຫ ອແລະຂ ມ ນຂ າວສານທ ເປ ນພາສາຂອງທ າ ນບ ມ ຄ າໃຊ ຈ າຍ. ເພ ອຂ ຮ ອງນາຍພາສາ,ໂທຟຣຫາຫມາຍເລກໂທລະສ ບສ າລ ບ ສະມາຊ ກທ ໄດ ລະບ ໄວ ໃນບ ດສະມາຊ ກຂອງທ ານ,ກ ດເລກ TTY 711