Summary Plan Description 

Vermilion Parish School Board
‍Choice Plus Medical Plan

Effective: May 1, 2013
Group Number: 702173
 

Description: Y:\ASO_SPDs_Agreements\Medical SPDs\ASOMEDSPD Phase III\Proj#19928_11152012_PhaseIII_Maintenance_Updates_0407NA_ATB\UHCLogoK.jpg

 

TABLE OF CONTENTS

SECTION 1 - WELCOME........................................................................................................ 1

SECTION 2 - INTRODUCTION................................................................................................ 3

Eligibility..................................................................................................................................................... 3

Cost of Coverage...................................................................................................................................... 3

How to Enroll........................................................................................................................................... 4

When Coverage Begins........................................................................................................................... 4

Changing Your Coverage....................................................................................................................... 5

SECTION 3 - HOW THE PLAN WORKS.................................................................................. 7

Network and Non-Network Benefits................................................................................................. 7

Eligible Expenses..................................................................................................................................... 8

Annual Deductible................................................................................................................................... 9

Copayment.................................................................................................................................................. 9

Coinsurance................................................................................................................................................ 9

Out-of-Pocket Maximum....................................................................................................................... 9

SECTION 4 - PERSONAL HEALTH SUPPORT...................................................................... 11

Requirements for Notifying Personal Health Support............................................................... 12

Special Note Regarding Medicare..................................................................................................... 13

SECTION 5 - PLAN HIGHLIGHTS......................................................................................... 14

SECTION 6 - ADDITIONAL COVERAGE DETAILS................................................................. 22

Section 6.1 Medical Services in a Physician's Office................................................................... 22

Section 6.2 Eye Examinations............................................................................................................ 23

Section 6.3 Allergy Services in a Physician’s Office..................................................................... 23

Section 6.4 Professional Fees for Surgical and Medical Services............................................. 23

Section 6.5 Inpatient Hospital and Related Covered Health Services................................... 23

Section 6.6 Transplantation Health Services.................................................................................. 23

Section 6.7 Emergency Outpatient Health Services.................................................................... 24

Section 6.8 Urgent Care....................................................................................................................... 24

Section 6.9 Outpatient Surgery, Diagnostic and Therapeutic Services.................................. 24

Section 6.10 Maternity Services......................................................................................................... 24

Section 6.11 Mental Health Benefits................................................................................................ 25

Section 6.12 Neurobiological Disorders – Mental Health Services for Autism Spectrum Disorders.................................................................................................................................................. 26

Section 6.13 Substance Use Disorder Services.............................................................................. 27

Section 6.14 Home Health Agency Services.................................................................................. 28

Section 6.15 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services............... 28

Section 6.16 Hospice Care................................................................................................................... 29

Section 6.17 Ambulance Services...................................................................................................... 29

Section 6.18 Accident-related Dental Services.............................................................................. 29

Section 6.19 Prosthetic Devices, Hearing Aids and Durable Medical Equipment............ 29

Section 6.20 Outpatient Rehabilitation Services.......................................................................... 31

Section 6.21 Infertility Services.......................................................................................................... 31

Section 6.22 Chiropractic Health Services, Spinal Treatment or Care.................................. 31

SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY................................................. 32

Consumer Solutions and Self-Service Tools.................................................................................. 32

Disease and Condition Management Services............................................................................... 36

Wellness Programs................................................................................................................................. 37

SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER....................... 38

Alternative Treatments......................................................................................................................... 38

Dental........................................................................................................................................................ 38

Devices, Appliances and Prosthetics................................................................................................ 39

Drugs......................................................................................................................................................... 40

Experimental or Investigational or Unproven Services............................................................. 40

Foot Care.................................................................................................................................................. 41

Medical Supplies..................................................................................................................................... 41

Mental Health/Substance Use Disorder......................................................................................... 41

Nutrition................................................................................................................................................... 43

Personal Care, Comfort or Convenience........................................................................................ 43

Physical Appearance.............................................................................................................................. 44

Preexisting Conditions......................................................................................................................... 45

Procedures and Treatments................................................................................................................. 45

Providers................................................................................................................................................... 46

Reproduction........................................................................................................................................... 47

Services Provided under Another Plan........................................................................................... 47

Transplants............................................................................................................................................... 47

Travel......................................................................................................................................................... 48

Types of Care........................................................................................................................................... 48

Vision and Hearing................................................................................................................................ 48

All Other Exclusions............................................................................................................................ 49

SECTION 9 - CLAIMS PROCEDURES.................................................................................. 51

Network Benefits.................................................................................................................................... 51

Non-Network Benefits......................................................................................................................... 51

Prescription Drug Benefit Claims..................................................................................................... 51

If Your Provider Does Not File Your Claim................................................................................ 51

Health Statements.................................................................................................................................. 52

Explanation of Benefits (EOB)......................................................................................................... 53

Claim Denials and Appeals................................................................................................................. 53

Federal External Review Program.................................................................................................... 54

Limitation of Action............................................................................................................................. 60

SECTION 10 - COORDINATION OF BENEFITS (COB).......................................................... 61

Determining Which Plan is Primary................................................................................................ 61

When This Plan is Secondary............................................................................................................. 62

When a Covered Person Qualifies for Medicare.......................................................................... 63

Right to Receive and Release Needed Information..................................................................... 64

Overpayment and Underpayment of Benefits............................................................................... 64

SECTION 11 - SUBROGATION AND REIMBURSEMENT...................................................... 66

Right of Recovery.................................................................................................................................. 66

Right to Subrogation............................................................................................................................ 66

Right to Reimbursement...................................................................................................................... 67

Third Parties............................................................................................................................................ 67

Subrogation and Reimbursement Provisions................................................................................ 67

SECTION 12 - WHEN COVERAGE ENDS............................................................................. 70

Coverage for a Disabled Child........................................................................................................... 71

Extended Coverage for Total Disability......................................................................................... 71

Continuing Coverage Through COBRA........................................................................................ 72

When COBRA Ends............................................................................................................................ 75

Uniformed Services Employment and Reemployment Rights Act......................................... 76

SECTION 13 - OTHER IMPORTANT INFORMATION............................................................. 78

Qualified Medical Child Support Orders (QMCSOs)............................................................... 78

Your Relationship with UnitedHealthcare and Vermilion Parish School Board............... 78

Relationship with Providers................................................................................................................ 79

Your Relationship with Providers.................................................................................................... 79

Interpretation of Benefits.................................................................................................................... 80

Information and Records..................................................................................................................... 80

Incentives to Providers......................................................................................................................... 81

Incentives to You................................................................................................................................... 82

Rebates and Other Payments.............................................................................................................. 82

Workers' Compensation Not Affected............................................................................................ 82

Future of the Plan.................................................................................................................................. 82

Plan Document....................................................................................................................................... 82

SECTION 14 - GLOSSARY................................................................................................... 84

SECTION 15 - PRESCRIPTION DRUGS................................................................................ 98

Prescription Drug Coverage Highlights.......................................................................................... 98

Identification Card (ID Card) – Network Pharmacy.................................................................. 99

Benefit Levels.......................................................................................................................................... 99

Retail........................................................................................................................................................ 100

Mail Order............................................................................................................................................. 101

Benefits for Preventive Care Medications.................................................................................... 101

Designated Pharmacy.......................................................................................................................... 101

Assigning Prescription Drugs to the PDL................................................................................... 102

Notification Requirements................................................................................................................ 103

Prescription Drug Benefit Claims................................................................................................... 104

Limitation on Selection of Pharmacies.......................................................................................... 104

Supply Limits........................................................................................................................................ 104

If a Brand-name Drug Becomes Available as a Generic.......................................................... 104

Special Programs.................................................................................................................................. 104

Prescription Drug Products Prescribed by a Specialist Physician......................................... 105

Rebates and Other Discounts.......................................................................................................... 105

Coupons, Incentives and Other Communications.................................................................... 105

Exclusions - What the Prescription Drug Plan Will Not Cover........................................... 105

Glossary - Prescription Drugs.......................................................................................................... 107

ATTACHMENT I - HEALTH CARE REFORM NOTICES........................................................ 111

Patient Protection and Affordable Care Act ("PPACA")....................................................... 111

ATTACHMENT II - LEGAL  Notices..................................................................................... 112

Women's Health and Cancer Rights Act of 1998...................................................................... 112

Statement of Rights under the Newborns' and Mothers' Health Protection Act............ 112

ADDENDUM - UNITEDHEALTH ALLIES.............................................................................. 113

Introduction.......................................................................................................................................... 113

What is UnitedHealth Allies?........................................................................................................... 113

Selecting a Discounted Product or Service.................................................................................. 113

Visiting Your Selected Health Care Professional...................................................................... 113

Additional UnitedHealth Allies Information.............................................................................. 114

ADDENDUM - PARENTSTEPS®.......................................................................................... 115

Introduction.......................................................................................................................................... 115

What is ParentSteps?........................................................................................................................... 115

Registering for ParentSteps.............................................................................................................. 115

Selecting a Contracted Provider...................................................................................................... 115

Visiting Your Selected Health Care Professional...................................................................... 116

Obtaining a Discount......................................................................................................................... 116

Speaking with a Nurse........................................................................................................................ 116

Additional ParentSteps Information.............................................................................................. 116

 

 


SECTION 1 - WELCOME

Quick Reference Box

      Member services, claim inquiries, Personal Health Support and Mental Health/Substance Use Disorder Administrator: 1-866-844-4864‍‍‍;

      Claims submittal address: UnitedHealthcare - Claims, P.O. Box 30555 Salt Lake City, Utah 84130-0555; and

      Online assistance: www.myuhc.com.

Vermilion Parish School Board is pleased to provide you with this Summary Plan Description (SPD), which describes the health Benefits available to you and your covered family members under the Vermillion Parish School Board Welfare Benefit Plan. It includes summaries of:

      who is eligible;

      services that are covered, called Covered Health Services;

      services that are not covered, called Exclusions;

      how Benefits are paid; and

      your rights and responsibilities under the Plan.

This SPD supersedes any previous printed or electronic SPD for this Plan.

Vermilion Parish School Board intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice subject to any collective bargaining agreements between the Employer and various unions, if applicable. This SPD is not to be construed as a contract of or for employment. If there should be an inconsistency between the contents of this summary and the contents of the Plan, your rights shall be determined under the Plan and not under this summary.

UnitedHealthcare is a private healthcare claims administrator. UnitedHealthcare goal is to give you the tools you need to make wise healthcare decisions. UnitedHealthcare also helps your employer to administer claims. Although UnitedHealthcare will assist you in many ways, it does not guarantee any Benefits. Vermilion Parish School Board is solely responsible for paying Benefits described in this SPD.

Please read this SPD thoroughly to learn how the Vermillion Parish School Board Welfare Benefit Plan works. If you have questions contact ‍‍‍the Benefits Department‍ or call the ‍‍number on the back of your ID card.


 

How To Use This SPD

      Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference.

      Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section.

      You can find copies of your SPD and any future amendments‍ or request printed copies by contacting ‍‍the Benefits Department.

      Capitalized words in the SPD have special meanings and are defined in Section 14, Glossary.

      If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 14, Glossary.

      Vermilion Parish School Board is also referred to as Company.

      If there is a conflict between this SPD and any benefit summaries (other than Summaries of Material Modifications) provided to you, this SPD will control.

 


SECTION 2 - INTRODUCTION

What this section includes:

      Who's eligible for coverage under the Plan;

      The factors that impact your cost for coverage;

      Instructions and timeframes for enrolling yourself and your eligible Dependents;

      When coverage begins; and

      When you can make coverage changes under the Plan.

Eligibility

You are eligible to enroll in the Plan if you are a regular full-time Employee who is scheduled to work at least 37.5 hours per week or a person who retires while covered under the Plan.

Vermilion Parish School Board members should be treated as eligible. Vermilion Parish School Board members should be treated as retirees after completing 12 years of service and ending their term on the Vermilion plan. There should be no difference between an eligible active full-time employee and a member for purposes of this plan.

Your eligible Dependents may also participate in the Plan. An eligible Dependent is considered to be:

      your Spouse, as defined in Section 14, Glossary;

      your or your Spouse's child who is under age 26, including a natural child, stepchild, a legally adopted child, a child placed for adoption or a child for whom you or your Spouse are the legal guardian; or

      an unmarried child age 26 or over who is or becomes disabled and dependent upon you.

To be eligible for coverage under the Plan, a Dependent must reside within the United States.

Note: Your Dependents may not enroll in the Plan unless you are also enrolled. If you and your Spouse are both covered under the Vermillion Parish School Board Welfare Benefit Plan, you may each be enrolled as an Employee or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under the Vermillion Parish School Board Welfare Benefit Plan, only one parent may enroll your child as a Dependent.

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order, as described in Section 13, Other Important Information.

Cost of Coverage

You and Vermilion Parish School Board share in the cost of the Plan. Your contribution amount depends on the Plan you select and the family members you choose to enroll.

Your contributions are deducted from your paychecks on a before-tax basis. Before-tax dollars come out of your pay before federal income and Social Security taxes are withheld - and in most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you.

For retirees, your contributions are deducted from your monthly pension check.

Your contributions are subject to review and Vermilion Parish School Board reserves the right to change your contribution amount from time to time.

You can obtain current contribution rates by calling ‍‍the Benefits Department‍.

How to Enroll

To enroll, call ‍‍the Benefits Department‍ within 31 days of the date you first become eligible for medical Plan coverage. If you do not enroll within 31 days, you will need to wait until the next annual Open Enrollment to make your benefit elections.

Each year during annual Open Enrollment, you have the opportunity to review and change your medical election. Any changes you make during Open Enrollment will become effective the following May 1.

Important

If you wish to change your benefit elections following your marriage, birth, adoption of a child, placement for adoption of a child or other family status change, you must contact ‍‍the Benefits Department within 31 days of the event. Otherwise, you will need to wait until the next annual Open Enrollment to change your elections.

When Coverage Begins

Once ‍‍the Benefits Department receives your properly completed enrollment, coverage will begin on ‍‍‍the first day of the month following the completion of a 31 days waiting period.‍ Coverage for your Dependents will start on the date your coverage begins, provided you have enrolled them in a timely manner.

Coverage for a Spouse or Dependent stepchild that you acquire via marriage becomes effective the first of the month following the date ‍‍the Benefits Department receives notice of your marriage, provided you notify ‍‍the Benefits Department within 31 days of your marriage. Coverage for Dependent children acquired through birth, adoption, or placement for adoption is effective the date of the family status change, provided you notify ‍‍the Benefits Department within 31 days of the birth, adoption, or placement.

If You Are Hospitalized When Your Coverage Begins

If you are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the day your coverage begins, the Plan will pay Benefits for Covered Health Services related to that Inpatient Stay as long as you receive Covered Health Services in accordance with the terms of the Plan.

You should notify UnitedHealthcare within 48 hours of the day your coverage begins, or as soon as is reasonably possible. Network Benefits are available only if you receive Covered Health Services from Network providers.

Changing Your Coverage

You may make coverage changes during the year only if you experience a change in family status. The change in coverage must be consistent with the change in status (e.g., you cover your Spouse following your marriage, your child following an adoption, etc.). The following are considered family status changes for purposes of the Plan:

      your marriage, divorce, legal separation or annulment;

      the birth, adoption, placement for adoption or legal guardianship of a child;

      a change in your Spouse's employment or involuntary loss of health coverage (other than coverage under the Medicare or Medicaid programs) under another employer's plan;

      loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you were paying for premiums on a timely basis;

      the death of a Dependent;

      your Dependent child no longer qualifying as an eligible Dependent;

      a change in your or your Spouse's position or work schedule that impacts eligibility for health coverage;

      contributions were no longer paid by the employer (This is true even if you or your eligible Dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer);

      you or your eligible Dependent who were enrolled in an HMO no longer live or work in that HMO's service area and no other benefit option is available to you or your eligible Dependent;

      benefits are no longer offered by the Plan to a class of individuals that include you or your eligible Dependent;

      termination of your or your Dependent's Medicaid or Children's Health Insurance Program (CHIP) coverage as a result of loss of eligibility (you must contact ‍‍the Benefits Department within 60 days of termination);

      you or your Dependent become eligible for a premium assistance subsidy under Medicaid or CHIP (you must contact ‍‍the Benefits Department within 60 days of determination of subsidy eligibility);

      a strike or lockout involving you or your Spouse; or

      a court or administrative order.

Unless otherwise noted above, if you wish to change your elections, you must contact ‍‍the Benefits Department within 31 days of the change in family status. Otherwise, you will need to wait until the next annual Open Enrollment.

While some of these changes in status are similar to qualifying events under COBRA, you, or your eligible Dependent, do not need to elect COBRA continuation coverage to take advantage of the special enrollment rights listed above. These will also be available to you or your eligible Dependent if COBRA is elected.

Note: Any child under age 26 who is placed with you for adoption will be eligible for coverage on the date the child is placed with you, even if the legal adoption is not yet final. If you do not legally adopt the child, all medical Plan coverage for the child will end when the placement ends. No provision will be made for continuing coverage (such as COBRA coverage) for the child.

Change in Family Status - Example

Jane is married and has two children who qualify as Dependents. At annual Open Enrollment, she elects not to participate in Vermilion Parish School Board's medical plan, because her husband, Tom, has family coverage under his employer's medical plan. In June, Tom loses his job as part of a downsizing. As a result, Tom loses his eligibility for medical coverage. Due to this family status change, Jane can elect family medical coverage under Vermilion Parish School Board's medical plan outside of annual Open Enrollment.

 


SECTION 3 - HOW THE PLAN WORKS

What this section includes:

      Network and Non-Network Benefits;

      Eligible Expenses;

      Annual Deductible;

      Copayment;

      Coinsurance; and

      Out-of-Pocket Maximum.

Network and Non-Network Benefits

As a participant in this Plan, you have the freedom to choose the Physician or health care professional you prefer each time you need to receive Covered Health Services. The choices you make affect the amounts you pay, as well as the level of Benefits you receive and any benefit limitations that may apply.

You are eligible for the Network level of Benefits under this Plan when you receive Covered Health Services from Physicians and other health care professionals who have contracted with ‍‍UnitedHealthcare to provide those services.

You can choose to receive ‍Network Benefits or Non-Network Benefits.

Network Benefits apply to Covered Health Services that are provided by a Network Physician or other Network provider. Emergency Health Services are always paid as Network Benefits. For facility charges, these are Benefits for Covered Health Services that are billed by a Network facility and provided under the direction of either a Network or non-Network Physician or other provider. Network Benefits include Physician services provided in a Network facility by a Network or a non-Network radiologist, anesthesiologist, pathologist and Emergency room Physician.

Non-Network Benefits apply to Covered Health Services that are provided by a non-Network Physician or other non-Network provider, or Covered Health Services that are provided at a non-Network facility.‍‍

Generally, when you receive Covered Health Services from a Network provider, you pay less than you would if you receive the same care from a non-Network provider. Therefore, in most instances, your out-of-pocket expenses will be less if you use a Network provider.

If you choose to seek care outside the Network, the Plan generally pays Benefits at a lower level. You are required to pay the amount that exceeds the Eligible Expense. The amount in excess of the Eligible Expense could be significant, and this amount does not apply to the Out-of-Pocket Maximum. You may want to ask the non-Network provider about their billed charges before you receive care.

Health Services from Non-Network Providers Paid as Network Benefits

If specific Covered Health Services are not available from a Network provider, you may be eligible to receive Network Benefits from a non-Network provider. In this situation, your Network Physician will notify ‍Personal Health Support, and they will work with you and your Network Physician to coordinate care through a non-Network provider.

When you receive Covered Health Services through a Network Physician, the Plan will pay Network Benefits for those Covered Health Services, even if one or more of those Covered Health Services is received from a non-Network provider.

Looking for a Network Provider?

In addition to other helpful information, www.myuhc.com‍, UnitedHealthcare's consumer website, contains a directory of health care professionals and facilities in UnitedHealthcare's Network. While Network status may change from time to time, www.myuhc.com has the most current source of Network information. Use www.myuhc.com to search for Physicians available in your Plan.

Network Providers

UnitedHealthcare or its affiliates arrange for health care providers to participate in a Network. ‍At your request, UnitedHealthcare will send you a directory of Network providers free of charge. ‍Keep in mind, a provider's Network status may change. To verify a provider's status or request a provider directory, you can call UnitedHealthcare at the toll-free ‍‍number on your ID card or log onto www.myuhc.com.

Network providers are independent practitioners and are not employees of Vermilion Parish School Board or UnitedHealthcare.

Possible Limitations on Provider Use

If UnitedHealthcare determines that you are using health care services in a harmful or abusive manner, you may be required to select a Network Physician to coordinate all of your future Covered Health Services. If you don't make a selection within 31 days of the date you are notified, UnitedHealthcare will select a Network Physician for you. In the event that you do not use the Network Physician to coordinate all of your care, any Covered Health Services you receive will be paid at the non-Network level.

Eligible Expenses

Eligible Expenses are charges for Covered Health Services that are provided while the Plan is in effect, determined according to the definition in Section 14, Glossary. For certain Covered Health Services, the Plan will not pay these expenses until you have met your Annual Deductible. Vermilion Parish School Board has delegated to UnitedHealthcare the initial discretion and authority to decide whether a treatment or supply is a Covered Health Service and how the Eligible Expenses will be determined and otherwise covered under the Plan.

 

 

Don't Forget Your ID Card

Remember to show your UnitedHealthcare ID card every time you receive health care services from a provider. If you do not show your ID card, a provider has no way of knowing that you are enrolled under the Plan.

Annual Deductible

The Annual Deductible is the amount of Eligible Expenses you must pay each calendar year for Covered Health Services before you are eligible to begin receiving Benefits. There are separate Network and non-Network Annual Deductibles for this Plan.‍‍ The amounts you pay toward your Annual Deductible accumulate over the course of the calendar year.

Amounts paid toward the Annual Deductible for Covered Health Services that are subject to a visit or day limit will also be calculated against that maximum benefit limit. As a result, the limited benefit will be reduced by the number of days or visits you used toward meeting the Annual Deductible.

Copayment

A Copayment (Copay) is the amount you pay each time you receive certain Covered Health Services. The Copay is a flat dollar amount and is paid at the time of service or when billed by the provider. Copays do not count toward the Out-of-Pocket-Maximum, except as described in Section 15, Prescription Drugs. Copays do not count toward the Annual Deductible. If the Eligible Expense is less than the Copay, you are only responsible for paying the Eligible Expense and not the Copay.

Coinsurance

Coinsurance is the percentage of Eligible Expenses that you are responsible for paying. Coinsurance is a fixed percentage that applies to certain Covered Health Services after you meet the Annual Deductible.

Coinsurance – Example

Let's assume that you receive Plan Benefits for outpatient surgery from a Network provider. Since the Plan pays 80% after you meet the Annual Deductible, you are responsible for paying the other 20%. This 20% is your Coinsurance.

Out-of-Pocket Maximum

The annual Out-of-Pocket Maximum is the most you pay each calendar year for Covered Health Services. There are separate Network and non-Network Out-of-Pocket Maximums for this Plan.‍‍‍ If your eligible out-of-pocket expenses in a calendar year exceed the annual maximum, the Plan pays 100% of Eligible Expenses for Covered Health Services through the end of the calendar year.‍

The following table identifies what does and does not apply toward your Network and non-Network Out-of-Pocket Maximums:

Plan Features

Applies to the Network Out-of-Pocket Maximum?

Applies to the Non-Network Out-of-Pocket Maximum?

Copays‍

No

No

Payments toward the Annual Deductible

No

No

Coinsurance Payments

Yes

Yes

Charges for non-Covered Health Services

No

No

The amounts of any reductions in Benefits you incur by not notifying Personal Health Support‍‍

No

No

Charges that exceed Eligible Expenses

No

No

 


SECTION 4 - PERSONAL HEALTH SUPPORT‍

What this section includes:

      An overview of the Personal Health Support‍ program; and

      Covered Health Services for which you need to contact Personal Health Support‍.

UnitedHealthcare provides a program called Personal Health Support‍ designed to encourage personalized, efficient care for you and your covered Dependents‍.

Personal Health Support Nurses‍center their efforts on prevention, education, and closing any gaps in your care. The goal of the program is to ensure you receive the most appropriate and cost-effective services available. A Personal Health Support Nurse‍is notified when you or your provider calls the toll-free‍‍ number on your ID card regarding an upcoming treatment or service.

If you are living with a chronic condition or dealing with complex health care needs, UnitedHealthcare may assign to you a primary nurse, referred to as a Personal Health Support Nurse to guide you through your treatment. This assigned nurse will answer questions, explain options, identify your needs, and may refer you to specialized care programs. The Personal Health Support Nurse will provide you with their telephone number so you can call them with questions about your conditions, or your overall health and well-being.

Personal Health Support Nurses‍will provide a variety of different services to help you and your covered family members receive appropriate medical care. Program components are subject to change without notice. As of the publication of this SPD, the Personal Health Support Nurse‍ program includes:

      Admission counseling - For upcoming inpatient Hospital admissions for certain conditions, a Treatment Decision Support Nurse may call you to help answer your questions and to make sure you have the information and support you need for a successful recovery.

      Inpatient care management - If you are hospitalized, a nurse will work with your Physician to make sure you are getting the care you need and that your Physician's treatment plan is being carried out effectively.

      Readmission Management - This program serves as a bridge between the Hospital and your home if you are at high risk of being readmitted. After leaving the Hospital, if you have a certain chronic or complex condition, you may receive a phone call from a Personal Health Support Nurse to confirm that medications, needed equipment, or follow-up services are in place. The Personal Health Support Nurse will also share important health care information, reiterate and reinforce discharge instructions, and support a safe transition home.

      Risk Management - Designed for participants with certain chronic or complex conditions, this program addresses such health care needs as access to medical specialists, medication information, and coordination of equipment and supplies. Participants may receive a phone call from a Personal Health Support Nurse to discuss and share important health care information related to the participant's specific chronic or complex condition.

If you do not receive a call from a Personal Health Support Nurse‍ but feel you could benefit from any of these programs, please call the toll-free ‍‍number on your ID card.

Requirements for Notifying Personal Health Support‍

Network providers are generally responsible for notifying Personal Health Support‍ before they provide certain services to you. However, there are some Network Benefits for which you are responsible for notifying Personal Health Support‍

When you choose to receive certain Covered Health Services from non-Network providers, you are responsible for notifying Personal Health Support‍ before you receive these services. In many cases, your Non-Network Benefits will be reduced if Personal Health Support‍ is not notified.

The services that require Personal Health Support‍ notification are:

      Inpatient Hospital and Related Health Services, including maternity services that exceed the delivery timeframes as described in Section 6, Additional Coverage Details;

      Outpatient Surgery, Diagnostic and Therapeutic Services

      Home Health Agency Services

      Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

      Hospice Care

      Accident related Dental Services

      Prosthetic Devices and Durable Medical Equipment for items that will cost more than $1,000 to purchase or rent

      Outpatient Rehabilitation Services

      Mental Health Services - inpatient services (including Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility);

      Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders -inpatient services (including Partial Hospitalization/Day treatment and services at a Residential Treatment Facility);

      Substance Use Disorder Services - inpatient services (including Partial Hospitalization/Day Treatment and services at a Residential Treatment Facility); and

      Chiropractic Health Services, Spinal Treatment or Care

 

 

Contacting Personal Health Support‍ is easy.

Simply call the toll-free ‍‍number on your ID card.

Special Note Regarding Medicare

If you are enrolled in Medicare on a primary basis and Medicare pays benefits before the Plan, you are not required to notify Personal Health Support‍ before receiving Covered Health Services. Since Medicare pays benefits first, the Plan will pay Benefits second as described in Section 10, Coordination of Benefits (COB).


SECTION 5 - PLAN HIGHLIGHTS

The table below provides an overview of Copays that apply when you receive certain Covered Health Services, and outlines the Plan's Annual Deductible and Out-of-Pocket Maximum.

Plan Features

Network

Non-Network

Copays1

 

 

      Emergency Health Services

$100

$100

      Ambulance – air transportation

$150

$150

      Ambulance – ground transportation

$50

$50

      Hospital - Inpatient Hospital stay (Maximum of two Inpatient Hospital confinement co-pays per calendar year.

$750

$1,000

      Physician's Office Services – Primary

$25

Not Applicable

      Physician’s Office Services – Specialist

$50

Not Applicable

      Surgery – Outpatient Facility

$250

$500

      Urgent Care Center Services

$100

Not Applicable

Annual Deductible1,2

 

      Individual

$750

$1,500

      Family (not to exceed $750 per Covered Person for Network Provider and $1,500 per Covered Person for Non-Network Provider)

$1,500

$3,000

Annual Out-of-Pocket Maximum1,2

 

      Individual

$3,000

$8,000

      Family (not to exceed $3,000 per Covered Person for Network Provider and $6,000 per Covered Person for Non-Network Provider)

$6,000

$16,000

Lifetime Maximum Benefit3

There is no dollar limit to the amount the Plan will pay for essential Benefits during the entire period you are enrolled in this Plan.

Unlimited

1In addition to these Copays, you may be responsible for meeting the Annual Deductible for the Covered Health Services described in the chart on the following pages.

2Copays do not apply toward the Annual Deductible or the Out-of-Pocket Maximum. The Annual Deductible does not apply toward the Out-of-Pocket Maximum for any Covered Health Services.

3Generally the following are considered to be essential benefits under the Patient Protection and Affordable Care Act:
Ambulatory patient services; emergency services, hospitalization; maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment); prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.


 

This table provides an overview of the Plan's coverage levels. For detailed descriptions of your Benefits, refer to Section 6, Additional Coverage Details.

Covered Health Services1

Percentage of Eligible Expenses Payable by the Plan:

Network

Non-Network

6.1 Medical Services in a Physician's Office


Preventive Care

100% of Eligible Expenses

 


Preventive care is not Covered.

 

Breast Pumps

100%

Breast Pumps

Not Covered

 

All Other Services

$25 per visit,
$50 per Specialist visit, except for Copayments required for specific Health Services set forth below.

Does not apply to Out-of-Pocket Maximum.

 

No office visit Copayment applies for pre-natal care after the first visit.

COLONOSCOPY: Benefits are payable at 100% for one screening or diagnostic colonoscopy every 5 years for adult members regardless of age. Deductible, coinsurance or copay should not apply.

 

50% after you meet the Annual Deductible

6.2 Eye Examinations

Same as Section 6.1 Does not apply to Out-of-Pocket Maximum.

Refractive eye examinations are limited to one every two calendar years

50% of Eligible Expenses

Eye examinations for refractive errors are not Covered

6.3 Allergy Services in a Physician’s Office

Same as Section 6.1 No Copayment applies for injections.

50% of Eligible Expenses

6.4 Professional Fees for Surgical and Medical Services

80% of Eligible Expenses after you meet the Annual Deductible

50% of Eligible Expenses after you meet the Annual Deductible

6.5 Inpatient Hospital and Related Health Services

80% of Eligible Expenses after a $750 per Confinement Copay and after you meet the Annual Deductible.

Limited to two Confinement Copays per calendar year.

*50% of Eligible Expenses after a $1,000 per Confinement Copay and after you meet the Annual Deductible.

Limited to two Confinement Copays per calendar year.

6.6 Transplantation Health Services

Same as any other Network Covered Health Services if ordered by Network Physician and provided at or arranged by a Designated Facility

6.7 Emergency Outpatient Health Services

$100 per visit.

Copayment waived if Confined within 24 hours for the same condition.

6.8 Urgent Care

100% of Eligible Expenses after you pay a $50 Copay

Does not apply to Out-of-Pocket Maximum

100% of Eligible Expenses after you pay a $50 Copay

Does not apply to Out-of-Pocket Maximum

6.9 Outpatient Surgery, Diagnostic and Therapeutic Services

$250 per outpatient surgery admission.

100% for diagnostic and therapeutic services.

$500 per outpatient surgery admission.

50% for diagnostic and therapeutic services.

6.10 Maternity Services

Same as 6.1, 6.4, 6.5, and 6.8.

Same as 6.1, 6.4, 6.5, and 6.8.

      Medical Services in a Physician's Office

Benefits will be the same as those stated under each Covered Health Service category in this section.

      Inpatient Hospital and Related Health Services

Benefits will be the same as those stated under each Covered Health Service category in this section.

6.11 Mental Health Services

 

 

      Medical Services in a Physician's Office

100% of Eligible Expenses after you pay a $25 Copay

50% of Eligible Expenses after you meet the Annual Deductible

      Inpatient Hospital and Related Health Services

80% of Eligible Expenses after a $750 per Confinement Copay and after you meet the Annual Deductible

50% of Eligible Expenses after a $1,000 per Confinement Copay and after you meet the Annual Deductible.

6.12 Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders

Depending upon where the Covered Health Service is provided, benefits for outpatient Neurobiological Services - Autism Spectrum Disorder Services will be the same as those stated under Medical Services in a Physician's Office, and benefits for inpatient/intermediate Neurobiological Services - Autism Spectrum Disorder Services will be the same as those stated under Inpatient Hospital and Related Health Services in this Summary Plan Description.

6.13 Substance Use Disorder Services

 

 

      Medical Services in a Physician's Office

100% of Eligible Expenses after you pay a $25 Copay

50% of Eligible Expenses after you meet the Annual Deductible

      Inpatient Hospital and Related Health Services

80% of Eligible Expenses after a $750 per Confinement Copay and after you meet the Annual Deductible

50% of Eligible Expenses after a $1,000 per Confinement Copay and after you meet the Annual Deductible.

6.14 Home Health Agency Services

80% of Eligible Expenses after you meet the Annual Deductible

*50% of Eligible Expenses after you meet the Annual Deductible

6.15 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Limited to 100 days per calendar year

80% of Eligible Expenses ‍‍‍after you meet the Annual Deductible

No Copayment applies if a Covered Person is transferred to a Skilled Nursing Facility or Inpatient Rehabilitation Facility directly from an acute facility.

*50% of Eligible Expenses after you meet the Annual Deductible

6.16 Hospice Care

Limited to 185 days during the entire period of time a Covered Person is Covered under the Plan.

80% of Eligible Expenses after you meet the Annual Deductible

*50% of Eligible Expenses after you meet the Annual Deductible

6.17 Ambulance Services

Ground Transportation: 100% of Eligible Expenses after you pay a $50 Copay

Air Transportation: 100% of Eligible Expenses after you pay a $150 Copay

Ground Transportation: 100% of Eligible Expenses after you pay a $50 Copay

Air Transportation: 100% of Eligible Expenses after you pay a $150 Copay

6.18 Accident-related Dental Services

80% of Eligible Expenses after you meet the Annual Deductible

80% of Eligible Expenses after you meet the Annual Deductible

6.19 Prosthetic Devices, Hearing Aids and Durable Medical Equipment

 

 

Network and Non-Network Benefits for Prosthetic Devices and Durable Medical Equipment are subject to the combined limit of $1,500 per calendar year.

Any combination of Network Benefits and Non-Network Benefits for Hearing Aids is limited to $1,500 per calendar year.

Benefits are limited to a single purchase (including repair/replacement) per hearing impaired ear every three calendar years.

Once the limit for Prosthetic Devices is reached, Benefits continue to be available for items required by the Women's Health and Cancer Rights Act of 1998.

80% of Eligible Expenses after you meet the Annual Deductible

 

 

*50% of Eligible Expenses after you meet the Annual Deductible

*pre-notification required when the cost exceeds $300

6.20 Outpatient Rehabilitation Services

 

 

Network and Non-Network Benefits are subject to combined limits as follows:

60 visits of physical therapy per calendar year.

60 visits of occupational therapy per calendar year.

60 visits of speech therapy per calendar year.

36 visits of cardiac/pulmonary rehabilitation per calendar year.

80% of Eligible Expenses after you meet the Annual Deductible

50% of Eligible Expenses after you meet the Annual Deductible

6.21 Infertility Services

80% of Eligible Expenses after you meet the Annual Deductible

Not Covered

6.22 Chiropractic Health Services, Spinal Treatment or Care

Coverage is provided only for services provided in the Chiropractor’s office and is limited to a maximum of 20 office visits per calendar year.

100% of Eligible Expenses after you pay a $25 Copay

*50% of Eligible Expenses after you meet the Annual Deductible

1You must notify Personal Health Support‍, as described in Section 4, Personal Health Support‍ to receive full Benefits before receiving certain Covered Health Services from a non-Network provider. In general, if you visit a Network provider, that provider is responsible for notifying Personal Health Support‍ before you receive certain Covered Health Services. See Section 6, Additional Coverage Details for further information. Covered Health Services that are subject to notification are also marked with an *.

 


SECTION 6 - ADDITIONAL COVERAGE DETAILS

What this section includes:

      Covered Health Services for which the Plan pays Benefits; and

      Covered Health Services that require you to notify Personal Health Support‍ before you receive them, and any reduction in Benefits that may apply if you do not call Personal Health Support‍.

This section supplements the second table in Section 5, Plan Highlights.

While the table provides you with Benefit limitations along with Copayment, ‍Coinsurance and Annual Deductible information for each Covered Health Service, this section includes descriptions of the Benefits. These descriptions include any additional limitations that may apply, as well as Covered Health Services for which you must call Personal Health Support‍. The Covered Health Services in this section appear in the same order as they do in the table for easy reference. Services that are not covered are described in Section 8, Exclusions.

Section 6.1 Medical Services in a Physician's Office.

Benefits provided by or through a‍ Physician in the Physician's office. Benefits include preventive medical care such as well-baby care, routine physical examinations, vision and hearing screenings, voluntary family planning, and immunizations. Benefits under this section include hearing exams in case of Injury or Sickness.

Preventive care services provided on an outpatient basis at a Physician's office, an Alternate Facility or a Hospital encompass medical services that have been demonstrated by clinical evidence to be safe and effective in either the early detection of disease or in the prevention of disease, have been proven to have a beneficial effect on health outcomes and include the following as required under applicable law:

·       Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force.

·       Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

·       With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

·       With respect to women, such additional preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

Preventive care Benefits defined under the Health Resources and Services Administration (HRSA) requirement include the cost of renting one breast pump per Pregnancy in conjunction with childbirth. Benefits for breast pumps also include the cost of purchasing one breast pump per Pregnancy in conjunction with childbirth. These Benefits are described under Section 5, Plan Highlights under Covered Health Services.

Benefits are only available if breast pumps are obtained from a DME provider or Physician.

Section 6.2 Eye Examinations.

Eye examinations provided by a Provider in the Provider's office. Refraction examinations to detect vision impairment are limited to one every two calendar years.

Section 6.3 Allergy Services in a Physician’s Office.

Allergy Benefits including allergy injection provided by or through a Physician. Benefits must be received in the Physician's office.

Section 6.4 Professional Fees for Surgical and Medical Services.

Professional fees for surgical services and other medical care provided by or through a Physician. Benefits must be provided in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or Alternate Facility.‍

Section 6.5 Inpatient Hospital and Related Covered Health Services.

Benefits for an Inpatient Stay, including room and board, and services and supplies received during an Inpatient Stay (in a Semi-private Room) in a ‍Hospital. Benefits must be provided by or through a Physician. Certain Benefits rendered during a Covered Person's Inpatient Stay are subject to separate Benefit restrictions and/or Copayments as described elsewhere in this Summary Plan Description.

Please remember for Non-Network Benefits, you must notify ‍Personal Health Support as follows:

■ for elective admissions: five business days before admission or as soon as reasonably possible;

■ for Emergency admissions (also termed non-elective admissions): as soon as is reasonably possible.

If Personal Health Support is not notified, Benefits will be reduced to 50% of Eligible Expenses.‍‍‍‍‍‍

Section 6.6 Transplantation Health Services.

Benefits for transplants when ordered by your ‍‍ Physician, provided at or arranged by a Designated Facility for transplants and you notify Personal Health Support‍. Transplantation Health Services must be necessary, as determined by Personal Health Support‍, and rendered in accordance with UnitedHealthcare's transplant guidelines.

Coverage is provided for cornea, kidney, kidney/pancreas, liver, heart, lung, and heart/lung transplants.

Coverage is also provided for bone marrow transplants (either from the Covered Person or a compatible donor) and peripheral Stem Cell transplants, with or without high dose chemotherapy, rendered in accordance with UnitedHealthcare's transplant guidelines. Contact Personal Health Support‍ for information about UnitedHealthcare's transplant guidelines.

Section 6.7 Emergency Outpatient Health Services.

Benefits for stabilization or initiation of treatment of Emergency conditions provided on an outpatient basis at either a Hospital or an Alternate Facility.

Section 6.8 Urgent Care.

Benefits for services received at an Urgent Care Center. Urgently needed Benefits provided in a Physician’s office are Covered as described in Section 6.1. To ensure prompt payment of your claim, notify Personal Health Support‍within two working days after you receive Benefits at a non-Network Urgent Care Center.

Section 6.9 Outpatient Surgery, Diagnostic and Therapeutic Services.

Benefits for outpatient surgery, laboratory, radiological and other diagnostic tests and therapeutic treatments (such as chemotherapy) provided by or through a Physician. Benefits must be received at a Hospital or Alternate Facility.

Section 6.10 Maternity Services.

Maternity related medical, Hospital and other Benefits are treated as any other Sickness and/or Injury. Coverage includes prenatal and postnatal care, and Benefits received during childbirth. Special prenatal programs are available. To participate, you should notify Personal Health Support‍ during your first trimester, but no later than one month prior to the anticipated delivery date.

Coverage is provided for a minimum Inpatient Stay of at least 48 hours for a mother and newborn for any delivery other than a cesarean section, and at least 96 hours for a cesarean section delivery. These are federally mandated requirements under the Newborns' and Mothers' Health Protection Act of 1996 which apply to this Plan. The Hospital or other provider is not required to get authorization for the time periods stated above. Authorizations are required for longer lengths of stay. If the mother agrees, the attending Physician may discharge the mother and/or the newborn child earlier than these minimum timeframes.

You should notify Personal Health Support‍ as soon as reasonably possible in the event that an Inpatient Stay for the mother and/or the newborn will extend beyond these minimum time frames. The purpose of the notification is to coordinate with Personal Health Support‍ to ensure that all Covered Health Services related to the extended Inpatient Stay will be Covered. This notification request only applies to Inpatient Stays in non-Network Hospitals. Failure to obtain approval from Personal Health Support‍ for Benefits related to the extended Inpatient Stay will result in reduced Coverage.

Section 6.11 Mental Health Benefits.

Mental Health Services include those received on an inpatient basis in a Hospital or Alternate Facility, and those received on an outpatient basis in a provider’s office or at an Alternate Facility.

Benefits include the following services provided on either an outpatient or inpatient basis:

      diagnostic evaluations and assessment.

      treatment planning.

      referral services.

      medication management.

      individual, family, therapeutic group and provider-based case management services.

      crisis intervention.

Benefits include the following ser vices provided on an inpatient basis:

      Partial Hospitalization/Day Treatment.

      services at a Residential Treatment Facility.

Benefits include the following services on an outpatient basis:

      Intensive Outpatient Treatment.

The Mental Health/Substance Use Disorder Administrator determines coverage for the inpatient treatment. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.

You are encouraged to contact the Mental Health/Substance Use Disorder Administrator for referrals to providers and coordination of care.

Special Mental Health Programs and Services

Special programs and services that are contracted under the Mental Health/Substance Use Disorder Administrator may become available to you as part of your Mental Health Services benefit. The Mental Health Services Benefits and financial requirements assigned to these programs or services are based on the designation of the program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment, outpatient or a Transitional Care category of benefit use. Special programs or services provide access to services that are beneficial for the treatment of your Mental Illness which may not otherwise be covered under this Plan.‍ Any decision to participate in such program or service is at the discretion of the Covered Person and is not mandatory.

Please remember for Non-Network Benefits, you must notify the MH/SUD Administrator to receive inpatient Benefits. Please refer to Section 4, Personal Health Support‍ for the specific services that require notification. Please call the phone number that appears on your ID card. Without notification, Benefits will be reduced to 50% of Eligible Expenses.‍‍‍‍‍‍

Section 6.12 Neurobiological Disorders – Mental Health Services for Autism Spectrum Disorders.

The Plan pays Benefits for psychiatric services for Autism Spectrum Disorders that are both of the following:

      provided by or under the direction of an experienced psychiatrist and/or an experienced licensed psychiatric provider.

      focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others or property and impairment in daily functioning.

These Benefits describe only the psychiatric component of treatment for Autism Spectrum Disorders. Medical treatment of Autism Spectrum Disorders is a Covered Health Service for which Benefits are available under the applicable medical Covered Health Services categories as described in this section.

Benefits include the following services provided on either an outpatient or inpatient basis:

      diagnostic evaluations and assessment.

      treatment planning.

      referral services.

      medication management.

      individual, family, therapeutic group and provider-based case management services.

      crisis intervention.

Benefits include the following services provided on an inpatient basis:

      Partial Hospitalization/Day Treatment.

      services at a Residential Treatment Facility.

Benefits include the following services provided on an outpatient basis:

      Intensive Outpatient Treatment.

The Mental Health/Substance Use Disorder Administrator determines coverage for the inpatient treatment. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.

You are encouraged to contact the Mental Health/Substance Use Disorder Administrator for referrals to providers and coordination of care.

Please remember for Non-Network Benefits, you must notify the MH/SUD Administrator to receive inpatient Benefits. Please refer to Section 4, Personal Health Support‍ for the specific services that require notification. Please call the phone number that appears on your ID card. Without notification, Benefits will be reduced to 50% of Eligible Expenses.‍‍‍‍‍‍

Section 6.13 Substance Use Disorder Services.

Substance Use Disorder Services include those received on an inpatient basis in a Hospital or an Alternate Facility and those received on an outpatient basis in a provider's office or at an Alternate Facility.

Benefits include the following services provided on either an inpatient or outpatient basis:

      diagnostic evaluations and assessment.

      treatment planning.

      referral services.

      medication management.

      individual, family, therapeutic group and provider-based case management.

      crisis intervention.

      detoxification (sub-acute/non-medical).

Benefits include the following services provided on an inpatient basis:

      Partial Hospitalization/Day Treatment.

      services at a Residential Treatment Facility.

Benefits include the following services provided on an outpatient basis:

    Intensive Outpatient Treatment.

The Mental Health/Substance Use Disorder Administrator determines coverage for the inpatient treatment. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.

You are encouraged to contact the Mental Health/Substance Use Disorder Administrator for referrals to providers and coordination of care.

Special Substance Use Disorder Programs and Services

Special programs and services that are contracted under the Mental Health/Substance Use Disorder Administrator may become available to you as part of your Substance Use Disorder Services benefit. The Substance Use Disorder Services Benefits and financial requirements assigned to these programs or services are based on the designation of the program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment, outpatient or a Transitional Care category of benefit use. Special programs or services provide access to services that are beneficial for the treatment of your substance use disorder which may not otherwise be covered under this Plan.‍ Any decision to participate in such program or service is at the discretion of the Covered Person and is not mandatory.

Please remember for Non-Network Benefits, you must notify the MH/SUD Administrator to receive inpatient Benefits. Please refer to Section 4, Personal Health Support‍ for the specific services that require notification. Please call the phone number that appears on your ID card. Without notification, Benefits will be reduced to 50% of Eligible Expenses.‍‍‍‍‍‍

Section 6.14 Home Health Agency Services.

Part-time, intermittent Benefits from a‍ Home Health Agency, when provided under the direction of a Physician. Home Health Agency services are Covered only when Skilled Care Services are determined to be Covered Health Services. Home Health Agency Services must be provided in your home, by or under the supervision of a registered nurse. Personal Health Support‍ will decide if Skilled Care is needed by reviewing both the skilled nature of the service and the need for Physician-directed medical management. A service will not be determined to be “skilled” simply because there is not an available caregiver.

Please remember for Non-Network Benefits, you must notify ‍Personal Health Support or as soon as reasonably possible. If Personal Health Support‍ is not notified, Benefits will be reduced to 50% of Eligible Expenses.‍‍‍‍‍‍

Section 6.15 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services.

Inpatient Stay (in a Semi-private Room), including medical services and supplies, when provided under the direction of a Physician. Benefits must be provided in a ‍ Skilled Nursing Facility or ‍ Inpatient Rehabilitation Facility and are Covered only for the care and treatment of an Injury or Sickness which otherwise would require Inpatient Stay in a ‍ Hospital. Personal Health Support‍ will determine if Benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. A service will not be determined to be "skilled" simply because there is not an available caregiver. Coverage is limited as stated in Section 5, Plan Highlights.

Please remember for Non-Network Benefits, you must notify ‍Personal Health Support as follows:

          ■ for elective admissions: five business days before admission;

          ■ for Emergency admissions (also termed non-elective admissions): as soon as is           reasonably possible.

If Personal Health Support is not notified, Benefits will be reduced to 50% of Eligible Expenses.‍‍‍‍‍‍

Section 6.16 Hospice Care.

Coverage for Hospice Care which is recommended by a Physician, and provided through a licensed hospice agency UnitedHealthcare identifies Contact Personal Health Support‍ for information about UnitedHealthcare's policies for Hospice Care.

Please remember for Non-Network Benefits, you must notify ‍Personal Health Support. If Personal Health Support‍ is not notified, Benefits will be reduced to 50% of Eligible Expenses.‍‍‍‍‍‍

Section 6.17 Ambulance Services.

Emergency ambulance transportation by a licensed ambulance service to the nearest Hospital where Emergency Outpatient Health Services can be rendered.

Section 6.18 Accident-related Dental Services.

Services performed by a Doctor of Dental Surgery, "D.D.S.", or Doctor of Medical Dentistry, "D.M.D.", for the treatment of any sound natural teeth made necessary as a result of an Injury. Coverage is provided only when services are required as a result of an Injury (except for an Injury resulting from biting or chewing) which occurs while you are Covered under the Plan. No Coverage is provided unless the dentist certifies to UnitedHealthcare, on behalf of the Plan Administrator, that teeth were sound natural teeth which were injured as a result of an accident. Services must be provided and completed within 6 months of the Injury. (A sound natural tooth has no decay, no filling on more than two surfaces, no gum disease associated with bone loss, no root canal therapy, is not a dental implant, and functions normally in chewing and speech.) No Coverage is provided for dental implants.

Please remember that you should notify ‍Personal Health Support as soon as possible, but at least five business days before follow-up (post-Emergency) treatment begins. You do not have to provide notification before the initial Emergency treatment. When you provide notification, ‍Personal Health Support can determine whether the service is a Covered Health Service.

Section 6.19 Prosthetic Devices, Hearing Aids and Durable Medical Equipment.

Coverage for prosthetic devices and Durable Medical Equipment must meet the following criteria: (1) approved in advance by Personal Health Support‍, (2) obtained from a vendor or Provider identified by UnitedHealthcare, and (3) ordered or provided by or under the direction of a Physician for use outside a‍ Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility.

Coverage is provided for prosthetics and Durable Medical Equipment which meet the minimum specifications and are considered to be Covered Health Services. Except when necessitated due to a change in your medical condition or to improve physical function, no Coverage is provided for repair, replacement or duplicates nor is Coverage provided for services related to the repair or replacement.

Benefits for prosthetic devices including artificial limbs or artificial eyes, external cochlear devices and systems, breast prosthesis following mastectomy as required by the Women's Health and Cancer Rights Act of 1998, including mastectomy bras and lymphedema stockings for the arm, and other external prosthetic devices made necessary as a result of Injury or Sickness, are limited to a single purchase of each type of prosthetic. (Prosthetic devices replace a limb or body part or help an impaired limb or body part work.)

Rental or purchase, at UnitedHealthcare's discretion, of Durable Medical Equipment, including, but not limited to, the following:

      Braces, including necessary adjustments to shoes to accommodate braces (dental braces are excluded);

      Oxygen and the rental of equipment for the administration of oxygen (includes tubing, connectors and mask);

      Standard wheelchairs;

      Standard Hospital-type beds;

      Delivery pumps for tube feedings (includes tubing and connectors);

      Mechanical equipment necessary for the treatment of chronic or acute respiratory failure (except that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters, and other personal comfort items are excluded).

Coverage is limited as stated in Section 5, Plan Highlights.

Please remember for Non-Network Benefits, you must notify ‍Personal Health Support if the retail purchase cost or cumulative rental cost of a single item will exceed $300. To receive Network Benefits, you must purchase or rent the DME from the vendor ‍Personal Health Support identifies or purchase it directly from the prescribing network Physician. If Personal Health Support‍ is not notified, Benefits will be reduced to 50% of Eligible Expenses.‍‍‍‍‍‍

The Plan pays Benefits for hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive sound which may range from slight to complete deafness). Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear. A hearing aid consists of a microphone, amplifier and receiver.

Benefits are available for a hearing aid that is purchased as a result of a written recommendation by a Physician. Benefits are provided for the hearing aid and for charges for associated fitting and testing.

Benefits do not include bone anchored hearing aids. Bone anchored hearing aids are a Covered Health Service for which Benefits are available under the applicable medical/surgical Covered Health Services categories in this section only for Covered Persons who have either of the following:

      craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid; or

      hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid.

Section 6.20 Outpatient Rehabilitation Services.

Short-term outpatient rehabilitation services. Coverage is provided only for rehabilitation services (such as physical therapy, occupational therapy, speech therapy, and cardiac/pulmonary rehabilitation) which are expected to result in significant physical improvement in the Covered Person's condition within 2 months of start of treatment. Speech therapy is Covered only when required as a result of Injury, stroke or a Congenital Anomaly, as determined by Personal Health Support‍. Coverage is limited as stated in Section 5, Plan Highlights.

Rehabilitation services must be performed in a Hospital or Skilled Nursing Facility or through a‍ Home Health Agency or other ‍Provider. Rehabilitation services must be provided under the direction of a Physician and approved in advance by Personal Health Support‍.

Section 6.21 Infertility Services.

Benefits for the diagnosis and treatment of infertility when provided by or under the direction of your ‍‍ Physician. Coverage is provided only when Personal Health Support‍ determines, in advance, that such Benefits are considered to be Covered Health Services. Coverage is limited as stated in Section 5, Plan Highlights.

Please remember for Non-Network Benefits, you must notify ‍Personal Health Support as soon as the possibility of the need for infertility services arises. If Personal Health Support‍ is not notified, Benefits will be reduced to 50% of Eligible Expenses.‍‍‍‍‍‍

Section 6.22 Chiropractic Health Services, Spinal Treatment or Care.

Coverage is provided for Chiropractic Health Services, Treatment or Care provided by a‍ Chiropractor. Referrals to a‍ Chiropractor,‍ Hospital or‍ Alternate Facility or other‍ Provider shall be made at the sole discretion of Personal Health Support‍ on behalf of the Plan Administrator.

Please remember for Non-Network Benefits, you must notify ‍Personal Health Support five business days before receiving Chiropractic Health Services, Treatment or Care or as soon as reasonably possible. If Personal Health Support‍ is not notified, Benefits will be reduced to 50% of Eligible Expenses.‍‍‍‍‍‍

 


SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY

What this section includes:

Health and well-being resources available to you, including:

      Consumer Solutions and Self-Service Tools;

      Disease and Condition Management Services; and

      Wellness Programs.

Vermilion Parish School Board believes in giving you the tools you need to be an educated health care consumer. To that end, Vermilion Parish School Board has made available several convenient educational and support services, accessible by phone and the Internet, which can help you to:

      take care of yourself and your family members;

      manage a chronic health condition; and

      navigate the complexities of the health care system.

NOTE:

Information obtained through the services identified in this section is based on current medical literature and on Physician review. It is not intended to replace the advice of a doctor. The information is intended to help you make better health care decisions and take a greater responsibility for your own health. UnitedHealthcare and Vermilion Parish School Board are not responsible for the results of your decisions from the use of the information, including, but not limited to, your choosing to seek or not to seek professional medical care, or your choosing or not choosing specific treatment based on the text.

Consumer Solutions and Self-Service Tools

Health Assessment

You are invited to learn more about your health and wellness at www.myuhc.com and are encouraged to participate in the online health assessment. The health assessment is an interactive questionnaire designed to help you identify your healthy habits as well as potential health risks.

Your health assessment is kept confidential. Completing the assessment will not impact your Benefits or eligibility for Benefits in any way.

To find the health assessment, log in to www.myuhc.com. After logging in, access your personalized Health & Wellness page and click the Health Assessment link. If you need any assistance with the online assessment, please call the number on the back of your ID card.

Health Improvement Plan

You can start a Health Improvement Plan at any time. This plan is created just for you and includes information and interactive tools, plus online health coaching recommendations based on your profile.

Online coaching is available for:

      nutrition;

      exercise;

      weight management;

      stress;

      smoking cessation;

      diabetes; and

      heart health.

To help keep you on track with your Health Improvement Plan and online coaching, you’ll also receive personalized messages and reminders – Vermilion Parish School Board's way of helping you meet your health and wellness goals.

NurseLineSM

NurseLineSM is a toll-free telephone service that puts you in immediate contact with an experienced registered nurse any time, 24 hours a day, seven days a week‍. Nurses can provide health information for routine or urgent health concerns. When you call, a registered nurse may refer you to any additional resources that Vermilion Parish School Board has available to help you improve your health and well-being or manage a chronic condition. Call any time when you want to learn more about:

      a recent diagnosis;

      a minor Sickness or Injury;

      men's, women's, and children's wellness;

      how to take Prescription Drugs safely;

      self-care tips and treatment options;

      healthy living habits; or

      any other health related topic.

NurseLineSM gives you another convenient way to access health information. By calling the same toll-free ‍‍number, you can listen to one of the Health Information Library's over 1,100 recorded messages, with over half in Spanish.

NurseLineSM is available to you at no cost. To use this convenient service, simply call the toll-free ‍‍number on the back of your ID card.

Note: If you have a medical emergency, call 911 instead of calling NurseLineSM.

 

 

Your child is running a fever and it's 1:00 AM. What do you do?

Call NurseLineSM toll-free, any time, 24 hours a day, seven days a week. You can count on NurseLineSM to help answer your health questions.

With NurseLineSM, you also have access to nurses online. To use this service, log onto www.myuhc.com and click "Live Nurse Chat" in the top menu bar. You'll instantly be connected with a registered nurse who can answer your general health questions any time, 24 hours a day, seven days a week. You can also request an e-mailed transcript of the conversation to use as a reference.

Note: If you have a medical emergency, call 911 instead of logging onto www.myuhc.com.

Treatment Decision Support

In order to help you make informed decisions about your health care, UnitedHealthcare has a program called Treatment Decision Support. This program targets specific conditions as well as the treatments and procedures for those conditions.

This program offers:

      access to accurate, objective and relevant health care information;

      coaching by a nurse through decisions in your treatment and care;

      expectations of treatment; and

      information on high quality providers and programs.

Conditions for which this program is available include:

      back pain;

      knee & hip replacement;

      prostate disease;

      prostate cancer;

      benign uterine conditions;

      breast cancer; and

      coronary disease.

Participation is completely voluntary and without extra charge. If you think you may be eligible to participate or would like additional information regarding the program, please contact the ‍‍number on the back of your ID card.

UnitedHealth Premiumsm Program

UnitedHealthcare designates Network Physicians and facilities as UnitedHealth PremiumSM Program Physicians or facilities for certain medical conditions. Physicians and facilities are evaluated on two levels - quality and efficiency of care. The UnitedHealth PremiumSM Program was designed to:

      help you make informed decisions on where to receive care;

      provide you with decision support resources; and

      give you access to Physicians and facilities across areas of medicine that have met UnitedHealthcare's quality and efficiency criteria.

For details on the UnitedHealth PremiumSM Program including how to locate a UnitedHealth PremiumSM Physician or facility, log onto www.myuhc.com or call the toll-free number on your ID card.

www.myuhc.com

UnitedHealthcare's member website, www.myuhc.com, provides information at your fingertips anywhere and anytime you have access to the Internet. www.myuhc.com opens the door to a wealth of health information and convenient self-service tools to meet your needs.

With www.myuhc.com you can:

      research a health condition and treatment options to get ready for a discussion with your Physician;

      search for Network providers available in your Plan through the online provider directory;

      access all of the content and wellness topics from NurseLine including Live Nurse Chat 24 hours a day, seven days a week; 

      complete a health risk assessment to identify health habits you can improve, learn about healthy lifestyle techniques and access health improvement resources;

      use the treatment cost estimator to obtain an estimate of the costs of various procedures in your area; and

      use the Hospital comparison tool to compare Hospitals in your area on various patient safety and quality measures.

Registering on www.myuhc.com‍‍‍

If you have not already registered as a www.myuhc.comsubscriber, simply go to www.myuhc.com and click on "Register Now." Have your ‍UnitedHealthcare ID card handy. The enrollment process is quick and easy.

Visit www.myuhc.com and:

      make real-time inquiries into the status and history of your claims;

      view eligibility and Plan Benefit information, including Copays and Annual Deductibles;

      view and print all of your Explanation of Benefits (EOBs) online; and

      order a new or replacement ID card or, print a temporary ID card.

 

Want to learn more about a condition or treatment?

Log on to www.myuhc.com and research health topics that are of interest to you. Learn about a specific condition, what the symptoms are, how it is diagnosed, how common it is, and what to ask your Physician.

Disease and Condition Management Services

Disease Management Services

If you have been diagnosed with or are at risk for developing certain chronic medical conditions you may be eligible to participate in a disease management program at no cost to you. The heart failure, coronary artery disease, diabetes and asthma programs are designed to support you. This means that you will receive free educational information through the mail, and may even be called by a registered nurse who is a specialist in your specific medical condition. This nurse will be a resource to advise and help you manage your condition.

These programs offer:

      educational materials mailed to your home that provide guidance on managing your specific chronic medical condition. This may include information on symptoms, warning signs, self-management techniques, recommended exams and medications;

      access to educational and self-management resources on a consumer website;

      an opportunity for the disease management nurse to work with your Physician to ensure that you are receiving the appropriate care; and

      toll-free access to and one-on-one support from a registered nurse who specializes in your condition. Examples of support topics include: 

-        education about the specific disease and condition,

-        medication management and compliance,

-        reinforcement of on-line behavior modification program goals,

-        preparation and support for upcoming Physician visits,

-        review of psychosocial services and community resources,

-        caregiver status and in-home safety,

-        use of mail-order pharmacy and Network providers.

Participation is completely voluntary and without extra charge. If you think you may be eligible to participate or would like additional information regarding the program, please contact the ‍‍number on the back of your ID card.

HealtheNotesSM

UnitedHealthcare provides a service called HealtheNotes to help educate members and make suggestions regarding your medical care. HealtheNotes provides you and your Physician with suggestions regarding preventive care, testing or medications, potential interactions with medications you have been prescribed, and certain treatments. In addition, your HealtheNotes report may include health tips and other wellness information.

UnitedHealthcare makes these suggestions through a software program that provides retrospective, claims-based identification of medical care. Through this process patients are identified whose care may benefit from suggestions using the established standards of evidence based medicine as described in Section 14, Glossary under the definition of Covered Health Services.

If your Physician identifies any concerns after reviewing his or her HealtheNotes report, he or she may contact you if he or she believes it to be appropriate. In addition, you may use the information in your report to engage your Physician in discussions regarding your health and the identified suggestions. Any decisions regarding your care, though, are always between you and your Physician.

If you have questions or would like additional information about this service, please call the‍ number on the back of your ID card.

Wellness Programs

Healthy Pregnancy Program

If you are pregnant and enrolled in the medical Plan, you can get valuable educational information and advice by calling the toll-free ‍‍number on your ID card. This program offers:

      pregnancy consultation to identify special needs;

      written and on-line educational materials and resources;

      24-hour toll-free access to experienced maternity nurses;

      a phone call from a care coordinator during your Pregnancy, to see how things are going; and

      a phone call from a care coordinator approximately four weeks postpartum to give you information on infant care, feeding, nutrition, immunizations and more.

Participation is completely voluntary and without extra charge. To take full advantage of the program, you are encouraged to enroll within the first 12 weeks of Pregnancy. You can enroll any time, up to your 34th week. To enroll, call the toll-free ‍‍number on the back of your ID card.

As a program participant, you can call any time, 24 hours a day, seven days a week, with any questions or concerns you might have.

 


SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER

What this section includes:

      Services, supplies and treatments that are not Covered Health Services, except as may be specifically provided for in Section 6, Additional Coverage Details.

The Plan does not pay Benefits for the following services, treatments or supplies even if they are recommended or prescribed by a provider or are the only available treatment for your condition.

When Benefits are limited within any of the Covered Health Services categories described in Section 6, Additional Coverage Details, those limits are stated in the corresponding Covered Health Service category in Section 5, Plan Highlights. Limits may also apply to some Covered Health Services that fall under more than one Covered Health Service category. When this occurs, those limits are also stated in Section 5, Plan Highlights. Please review all limits carefully, as the Plan will not pay Benefits for any of the services, treatments, items or supplies that exceed these benefit limits.

Please note that in listing services or examples, when the SPD says "this includes," or "including but not limiting to", it is not UnitedHealthcare's intent to limit the description to that specific list. When the Plan does intend to limit a list of services or examples, the SPD specifically states that the list "is limited to."

Alternative Treatments

1.   acupressure;

2.   acupuncture;

3.   aromatherapy;

4.   hypnotism;

5.   massage therapy;

6.   rolfing (holistic tissue massage); and

7.   art therapy, music therapy, dance therapy, horseback therapy and other forms of alternative treatment as defined by the National Center for Complimentary and Alternative Medicine (NCCAM) of the National Institutes of Health This exclusion does not apply to Chiropractic Health Services non-manipulative osteopathic care for which Benefits are provided as described in Section 6, Additional Coverage Details.

Dental

1.   dental care, except as identified under Accident-related Dental Services in Section 6, Additional Coverage Details;

Dental care that is required to treat the effects of a medical condition, but that is not necessary to directly treat the medical condition, is excluded. Examples include treatment of dental caries resulting from dry mouth after radiation treatment or as a result of medication.

Endodontics, periodontal surgery and restorative treatment are excluded.

2.   diagnosis or treatment of or related to the teeth, jawbones or gums. Examples include:

-        extractions (including wisdom teeth);

-        restoration and replacement of teeth;

-        medical or surgical treatments of dental conditions; and

-        services to improve dental clinical outcomes;

This exclusion does not apply to accident-related dental services for which Benefits are provided as described under Accident-related Dental Services in Section 6, Additional Coverage Details.

3.   dental implants, bone grafts, and other implant-related procedures;

This exclusion does not apply to accident-related dental services for which Benefits are provided as described under Accident-related Dental Services in Section 6, Additional Coverage Details.

4.   dental braces (orthodontics);

5.   dental X-rays, supplies and appliances and all associated expenses, including hospitalizations and anesthesia; and

This exclusion does not apply to dental care (oral examination, X-rays, extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition for which Benefits are available under the Plan, as identified in Section 6, Additional Coverage Details.

6.   treatment of congenitally missing (when the cells responsible for the formation of the tooth are absent from birth), malpositioned or supernumerary (extra) teeth, even if part of a Congenital Anomaly such as cleft lip or cleft palate.

Devices, Appliances and Prosthetics

1.   devices used specifically as safety items or to affect performance in sports-related activities;

2.   orthotic appliances and devices that straighten or re-shape a body part, except as described under Prosthetic Devices and Durable Medical Equipment in Section 6, Additional Coverage Details:

Examples of excluded orthotic appliances and devices include but are not limited to, foot orthotics or any orthotic braces available over-the-counter.

3.   cranial banding;

4.   the following items are excluded, even if prescribed by a Physician:

-        blood pressure cuff/monitor;

-        enuresis alarm;

-        non-wearable external defibrillator;

-        trusses;

-        ultrasonic nebulizers;

except when necessitated due to a change in the Covered Person’s medical condition or to improve physical function, repair or replacement for any otherwise Covered Prosthetic Devices or Durable Medical Equipment is excluded;

5.   the repair and replacement of prosthetic devices when damaged due to misuse, malicious breakage or gross neglect;

6.   the replacement of lost or stolen prosthetic devices;

7.   devices and computers to assist in communication and speech except for speech aid devices and tracheo-esophageal voice devices for which Benefits are provided as described under Prosthetic Devices and Durable Medical Equipment in Section 6, Additional Coverage Details; and

8.   oral appliances for snoring.

Drugs

The exclusions listed below apply to the medical portion of the Plan only. Prescription Drug coverage is excluded under the medical plan because it is a separate benefit. Coverage may be available under the Prescription Drug portion of the Plan. See Section 15, Prescription Drugs, for coverage details and exclusions.

1.   Prescription Drugs for outpatient use that are filled by a prescription order or refill;

2.   self-injectable medications. (This exclusion does not apply to medications which, due to their characteristics, as determined by UnitedHealthcare, must typically be administered or directly supervised by a qualified provider or licensed/certified health professional in an outpatient setting);

3.   growth hormone therapy;

4.   non-injectable medications given in a Physician's office except as required in an Emergency and consumed in the Physician's office; and

5.   over the counter drugs and treatments.

Experimental or Investigational or Unproven Services

1.   Experimental or Investigational Services or Unproven Services, unless the Plan has agreed to cover them as defined in Section 14, Glossary.

      This exclusion applies even if Experimental or Investigational Services or Unproven Services, treatments, devices or pharmacological regimens are the only available treatment options for your condition.

Foot Care

1.   Orthotic appliances (including shoe orthotics);

2.   hygienic and preventive maintenance foot care. Examples include:

-        cleaning and soaking the feet;

-        applying skin creams in order to maintain skin tone; and

-        other services that are performed when there is not a localized Sickness, Injury or symptom involving the foot;


This exclusion does not apply to preventive foot care for Covered Persons who are at risk of neurological or vascular disease arising from diseases such as diabetes.

3.   treatment of flat feet;

4.   treatment of subluxation of the foot;

5.   shoe inserts;

6.   arch supports;

7.   shoes (standard or custom), lifts and wedges.

Medical Supplies

1.   outpatient prescribed or non-prescribed medical and disposable supplies. Examples of supplies that are not covered include, but are not limited to:

-        compression stockings, ace bandages, diabetic strips, and syringes;

-        ostomy bags and related supplies;

-        over-the-counter drugs and treatments; and

-        urinary catheters.

2.   tubings, nasal cannulas, connectors and masks except when used with Durable Medical Equipment;

3.   the repair and replacement of Durable Medical Equipment when damaged due to misuse, malicious breakage or gross neglect; and

4.   the replacement of lost or stolen Durable Medical Equipment.

Mental Health/Substance Use Disorder

Exclusions listed directly below apply to services described under Mental Health Services, Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders and/or Substance Use Disorder Services in Section 6, Additional Coverage Details.

1.   services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;

2.   services or supplies for the diagnosis or treatment of Mental Illness, alcoholism or substance use disorders that, in the reasonable judgment of the Mental Health/Substance Use Disorder Administrator, are any of the following:

-        not consistent with generally accepted standards of medical practice for the treatment of such conditions;

-        not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and therefore considered experimental;

-        not consistent with the Mental Health/Substance Use Disorder Administrator's level of care guidelines or best practices as modified from time to time; or

-        not clinically appropriate for the patient's Mental Illness, Substance Use Disorder or condition based on generally accepted standards of medical practice and benchmarks.

3.   Mental Health Services as treatments for V-code conditions as listed within the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;

4.   Mental Health Services as treatment for a primary diagnosis of insomnia and other sleep disorders, sexual dysfunction disorders, feeding disorders, neurological disorders and other disorders with a known physical basis;

5.   treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, personality disorders and paraphilias (sexual behavior that is considered deviant or abnormal);

6.   educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction and learning;

7.   tuition for or services that are school-based for children and adolescents under the Individuals with Disabilities Education Act;

8.   learning, motor skills and primary communication disorders as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;

9.   mental retardation and autism spectrum disorder as a primary diagnosis defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association;‍

10.  methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents for drug addiction;

11.  intensive behavioral therapies such as applied behavioral analysis for Autism Spectrum Disorders; and

12.  any treatments or other specialized services designed for Autism Spectrum Disorder that are not backed by credible research demonstrating that the services or supplies have a measurable and beneficial health outcome and therefore considered Experimental or Investigational or Unproven Services.

Nutrition

1.   nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or elements, and other nutrition based therapy;

2.   nutritional counseling;

3.   food of any kind. Foods that are not covered include:

-        enteral feedings and other nutritional and electrolyte formulas, including infant formula and donor breast milk. Infant formula available over the counter is always excluded;

-        foods to control weight, treat obesity (including liquid diets), lower cholesterol or control diabetes;

-        oral vitamins and minerals;

-        meals you can order from a menu, for an additional charge, during an Inpatient Stay; and

-        other dietary and electrolyte supplements; and

4.   health education classes unless offered by UnitedHealthcare or its affiliates, including but not limited to asthma, smoking cessation, and weight control classes.

Personal Care, Comfort or Convenience

1.   television;

2.   telephone;

3.   beauty/barber service;

4.   guest service;

5.   supplies, equipment and similar incidentals for personal comfort. Examples include:

-        air conditioners;

-        air purifiers and filters;

-        batteries and battery chargers;

-        dehumidifiers and humidifiers;

-        ergonomically correct chairs;

-        non-Hospital beds, comfort beds, motorized beds and mattresses;

-        breast pumps. This exclusion does not apply to breast pumps for which Benefits are provided under the Health Resources and Services Administration (HRSA) requirement;

-        car seats;

-        chairs, bath chairs, feeding chairs, toddler chairs, chair lifts and recliners;

-        electric scooters;

-        exercise equipment and treadmills;

-        hot tubs, Jacuzzis, saunas and whirlpools;

-        medical alert systems;

-        music devices;

-        personal computers;

-        pillows;

-        power-operated vehicles;

-        radios;

-        strollers;

-        safety equipment;

-        vehicle modifications such as van lifts;

-        video players; and

-        home modifications to accommodate a health need (including, but not limited to, ramps, swimming pools, elevators, handrails, and stair glides).

Physical Appearance

1.   Cosmetic Procedures, as defined in Section 14, Glossary, are excluded from coverage. Examples include:

-        liposuction or removal of fat deposits considered undesirable, including fat accumulation under the male breast and nipple;

-        pharmacological regimens;

-        nutritional procedures or treatments;

-        tattoo or scar removal or revision procedures (such as salabrasion, chemosurgery and other such skin abrasion procedures);

-        hair removal or replacement by any means;

-        treatments for skin wrinkles or any treatment to improve the appearance of the skin;

-        treatment for spider veins;

-        skin abrasion procedures performed as a treatment for acne;

-        treatments for hair loss;

-        varicose vein treatment of the lower extremities, when it is considered cosmetic; and

-        replacement of an existing intact breast implant if the earlier breast implant was performed as a Cosmetic Procedure;

2.   physical conditioning programs such as athletic training, bodybuilding, exercise, fitness, flexibility, health club memberships and programs, spa treatments, and diversion or general motivation;

3.   weight loss programs whether or not they are under medical supervision or for medical reasons, even if for morbid obesity;

4.   wigs regardless of the reason for the hair loss‍‍‍‍‍‍‍; and

5.   treatment of benign gynecomastia (abnormal breast enlargement in males).

Preexisting Conditions

1.   Benefits for the treatment of a Preexisting Condition are excluded unless you have had Continuous Creditable Coverage for 12 months. Preexisting Condition is defined in Section 14, Glossary.

This exclusion does not apply to Covered Persons under age 19.

Procedures and Treatments

1.   biofeedback;

2.   medical and surgical treatment of snoring, except when provided as a part of treatment for documented obstructive sleep apnea (a sleep disorder in which a person regularly stops breathing for 10 seconds or longer);

3.   rehabilitation services and Chiropractic Health Services, Treatment or Care to improve general physical condition that are provided to reduce potential risk factors, where significant therapeutic improvement is not expected, including routine, long-term or maintenance/preventive treatment;

4.   speech therapy to treat stuttering, stammering, or other articulation disorders;

5.   speech therapy, except when required for treatment of a speech impediment or speech dysfunction that results from Injury, stroke, cancer, a Congenital Anomaly or autism spectrum disorders as identified under Outpatient Rehabilitation Services in Section 6, Additional Coverage Details;

6.   a procedure or surgery to remove fatty tissue such as panniculectomy, abdominoplasty, thighplasty, brachioplasty, or mastopexy;

7.   excision or elimination of hanging skin on any part of the body (examples include plastic surgery procedures called abdominoplasty or abdominal panniculectomy and brachioplasty);

8.   psychosurgery (lobotomy);

9.   stand-alone multi-disciplinary smoking cessation programs. These are programs that usually include health care providers specializing in smoking cessation and may include a psychologist, social worker or other licensed or certified professional. The programs usually include intensive psychological support, behavior modification techniques and medications to control cravings;

10.  chelation therapy, except to treat heavy metal poisoning;

11.  Chiropractic Health Services, Treatment or Care to treat a condition unrelated to spinal manipulation and ancillary physiologic treatment rendered to restore/improve motion, reduce pain and improve function, such as asthma or allergies;

12.  physiological modalities and procedures that result in similar or redundant therapeutic effects when performed on the same body region during the same visit or office encounter;

13.  sex transformation operations and related services;

14.  the following treatments for obesity:

-        non-surgical treatment, even if for morbid obesity; and

-        surgical treatment of obesity even if there is a diagnosis of morbid obesity; and

15.  medical and surgical treatment of hyperhidrosis (excessive sweating);

16.  services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), when the services are considered medical or dental in nature;

17.  upper and lower jawbone surgery (including that related to the temporomandibular joint), orthognathic surgery and jaw alignment. This exclusion does not apply to reconstructive jaw surgery required for Covered Persons because of a Congenital Anomaly, acute traumatic Injury, dislocation, tumors, cancer or obstructive sleep apnea; and

18.  breast reduction surgery except as coverage is required by the Women's Health and Cancer Rights Act of 1998.

Providers

Services:

1.   performed by a provider who is a family member by birth or marriage, including your Spouse, brother, sister, parent or child;

2.   a provider may perform on himself or herself;

3.   performed by a provider  with your same legal residence;

4.   ordered or delivered by a Christian Science practitioner;

5.   performed by an unlicensed provider or a provider who is operating outside of the scope of his/her license;

6.   provided at a diagnostic facility (Hospital or free-standing) without a written order from a provider;

7.   which are self-directed to a free-standing or Hospital-based diagnostic facility; and

8.   ordered by a provider affiliated with a diagnostic facility (Hospital or free-standing), when that provider is not actively involved in your medical care:

-        prior to ordering the service; or

-        after the service is received.

This exclusion does not apply to mammography testing.

Reproduction

1.   health services and associated expenses for infertility treatments, including assisted reproductive technology, regardless of the reason for the treatment.

      This exclusion does not apply to services required to treat or correct underlying causes of infertility.

2.   storage and retrieval of all reproductive materials (examples include eggs, sperm, testicular tissue and ovarian tissue);

3.   in vitro fertilization regardless of the reason for treatment;

4.   surrogate parenting, donor eggs, donor sperm and host uterus;

5.   ‍the reversal of voluntary sterilization;

6.   artificial reproductive treatments done for genetic or eugenic (selective breeding) purposes, non-Medically Necessary amniocentesis (for example, determining sex);

7.   services provided by a doula (labor aide); and

8.   parenting, pre-natal or birthing classes.

Services Provided under Another Plan

Services for which coverage is available:

1.   under another plan, except for Eligible Expenses payable as described in Section 10, Coordination of Benefits (COB);

2.   under workers' compensation, no-fault automobile coverage or similar legislation if you could elect it, or could have it elected for you;

3.   while on active military duty; and

4.   for treatment of military service-related disabilities when you are legally entitled to other coverage, and facilities are reasonably accessible.

Transplants

1.   health services for organ and tissue transplants, except as identified under Transplantation Health Services in Section 6, Additional Coverage Details unless UnitedHealthcare determines the transplant to be appropriate according to UnitedHealthcare's transplant guidelines; Any solid organ transplant otherwise Covered under the Plan that is performed as a treatment for cancer.

2.   mechanical or animal organ transplants, except services related to the implant or removal of a circulatory assist device (a device that supports the heart while the patient waits for a suitable donor heart to become available);

3.   transplants that are not performed at a Designated Facility (this exclusion does not apply to cornea transplants); and

4.   donor costs for organ or tissue transplantation to another person (these costs may be payable through the recipient's benefit plan).

Travel

1.   health services provided in a foreign country, unless required as Emergency Outpatient Health Services; and

2.   travel or transportation expenses, even if ordered by a Physician. Additional travel expenses related to Covered Health Services received from a Designated Facility or Designated Physician may be reimbursed at the Plan’s discretion. This exclusion does not apply to ambulance transportation for which Benefits are provided as described under Ambulance Services in Section 6, Additional Coverage Details.

Types of Care

1.   Custodial Care as defined in Section 14, Glossary or maintenance care;

2.   Domiciliary Care, as defined in Section 14, Glossary;

3.   multi-disciplinary pain management programs provided on an inpatient basis for acute pain or for exacerbation of chronic pain;

4.   Private Duty Nursing;

5.   respite care. This exclusion does not apply to respite care that is part of an integrated hospice care program of services provided to a terminally ill person by a licensed hospice care agency for which Benefits are provided as described under Hospice Care in Section 6, Additional Coverage Details;

6.   rest cures;

7.   services of personal care attendants;

8.   work hardening (individualized treatment programs designed to return a person to work or to prepare a person for specific work).

Vision and Hearing

1.   routine vision examinations, including refractive examinations to determine the need for vision correction;

2.   implantable lenses used only to correct a refractive error (such as Intacs corneal implants);

3.   purchase cost and associated fitting charges for eyeglasses or contact lenses;

4.   bone anchored hearing aids except when either of the following applies:

-        for Covered Persons with craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid; or

-        for Covered Persons with hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid.

      The Plan will not pay for more than one bone anchored hearing aid per Covered Person who meets the above coverage criteria during the entire period of time the Covered Person is enrolled in this Plan. In addition, repairs and/or replacement for a bone anchored hearing aid for Covered Persons who meet the above coverage are not covered, other than for malfunctions;

5.   eye exercise, optometric therapy or vision therapy; and

6.   surgery and other related treatment that is intended to correct nearsightedness, farsightedness, presbyopia and astigmatism including, but not limited to, procedures such as laser and other refractive eye surgery and radial keratotomy.

All Other Exclusions

1.   autopsies and other coroner services and transportation services for a corpse;

2.   charges for:

-        missed appointments;

-        room or facility reservations;

-        completion of claim forms; or

-        record processing;

3.   charges prohibited by federal anti-kickback or self-referral statutes;

4.   diagnostic tests that are:

-        delivered in other than a Physician's office or health care facility; and

-        self-administered home diagnostic tests, including but not limited to HIV and Pregnancy tests;

5.   expenses for health services and supplies:

-        that do not meet the definition of a Covered Health Service in Section 14, Glossary;

-        that are received as a result of war or any act of war, whether declared or undeclared, while part of any armed service force of any country. This exclusion does not apply to Covered Persons who are civilians injured or otherwise affected by war, any act of war or terrorism in a non-war zone;

-        that are received after the date your coverage under this Plan ends, including health services for medical conditions which began before the date your coverage under the Plan ends;

-        for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under this Benefit Plan;

-        that exceed Eligible Expenses or any specified limitation in this SPD;

-        for which a non-Network provider waives the Copay, Annual Deductible or Coinsurance amounts;

6.   foreign language and sign language services;

7.   long term (more than 30 days) storage of blood, umbilical cord or other material. Examples include cryopreservation of tissue, blood and blood products;

8.   health services related to a non-Covered Health Service: When a service is not a Covered Health Service, all services related to that non-Covered Health Service are also excluded. This exclusion does not apply to services the Plan would otherwise determine to be Covered Health Services if they are to treat complications that arise from the non-Covered Health Service.

For the purpose of this exclusion, a "complication" is an unexpected or unanticipated condition that is superimposed on an existing disease and that affects or modifies the prognosis of the original disease or condition. Examples of a "complication" are bleeding or infections, following a Cosmetic Procedure, that require hospitalization.

9.   physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments when:

-        required solely for purposes of education, sports or camp, travel, career or employment, insurance, marriage or adoption; or as a result of incarceration;

-        conducted for purposes of medical research;

-        related to judicial or administrative proceedings or orders; or

-        required to obtain or maintain a license of any type.

 


SECTION 9 - CLAIMS PROCEDURES

What this section includes:

      How ‍Network and non-Network claims work; and

      What to do if your claim is denied, in whole or in part.

Network Benefits

In general, if you receive Covered Health Services from a Network provider, UnitedHealthcare will pay the Physician or facility directly. If a Network provider bills you for any Covered Health Service other than your Copay or Coinsurance, please contact the provider or call UnitedHealthcare at the ‍‍phone number on your ID card for assistance.

Keep in mind, you are responsible for meeting the Annual Deductible and paying any Copay or Coinsurance owed to a Network provider at the time of service, or when you receive a bill from the provider.

Non-Network Benefits

If you receive a bill for Covered Health Services from a non-Network provider‍, you (or the provider if they prefer) must send the bill to UnitedHealthcare for processing. To make sure the claim is processed promptly and accurately, a completed claim form must be attached and mailed to UnitedHealthcare at the address on the back of your ID card.‍

Prescription Drug Benefit Claims

If you wish to receive reimbursement for a prescription, you may submit a post-service claim as described in this section if:

      you are asked to pay the full cost of the Prescription Drug when you fill it and you believe that the Plan should have paid for it; or

      you pay a Copay and you believe that the amount of the Copay was incorrect.

If a pharmacy (retail or mail order) fails to fill a prescription that you have presented and you believe that it is a Covered Health Service, you may submit a pre-service request for Benefits as described in this section.

If Your Provider Does Not File Your Claim

You can obtain a claim form by visiting www.myuhc.com, calling the toll-free ‍‍number on your ID card or contacting ‍‍the Benefits Department. If you do not have a claim form, simply attach a brief letter of explanation to the bill, and verify that the bill contains the information listed below. If any of these items are missing from the bill, you can include them in your letter:

      your name and address;

      the patient's name, age and relationship to the Employee;

      the number as shown on your ID card;

      the name, address and tax identification number of the provider of the service(s);

      a diagnosis from the Physician;

      the date of service;

      an itemized bill from the provider that includes:

-        the Current Procedural Terminology (CPT) codes;

-        a description of, and the charge for, each service;

-        the date the Sickness or Injury began; and

-        a statement indicating either that you are, or you are not, enrolled for coverage under any other health insurance plan or program. If you are enrolled for other coverage you must include the name and address of the other carrier(s).

Failure to provide all the information listed above may delay any reimbursement that may be due you.

For medical claims, the above information should be filed with UnitedHealthcare at the address on your ID card. When filing a claim for outpatient Prescription Drug Benefits, submit your claim to the pharmacy benefit manager claims address noted on your ID card.

After UnitedHealthcare has processed your claim, you will receive payment for Benefits that the Plan allows. It is your responsibility to pay the non-Network provider the charges you incurred, including any difference between what you were billed and what the Plan paid.

UnitedHealthcare will pay Benefits to you unless:

      the provider notifies UnitedHealthcare that you have provided signed authorization to assign Benefits directly to that provider; or

      you make a written request for the non-Network provider to be paid directly at the time you submit your claim.

UnitedHealthcare will only pay Benefits to you or, with written authorization by you, your Provider, and not to a third party, even if your provider has assigned Benefits to that third party.

Health Statements

Each month in which UnitedHealthcare processes at least one claim for you or a covered Dependent, you will receive a Health Statement in the mail. Health Statements make it easy for you to manage your family's medical costs by providing claims information in easy-to-understand terms.

If you would rather track claims for yourself and your covered Dependents online, you may do so at www.myuhc.com. You may also elect to discontinue receipt of paper Health Statements by making the appropriate selection on this site.

Explanation of Benefits (EOB)

You may request that UnitedHealthcare send you a paper copy of an Explanation of Benefits (EOB) after processing the claim. The EOB will let you know if there is any portion of the claim you need to pay. If any claims are denied in whole or in part, the EOB will include the reason for the denial or partial payment. If you would like paper copies of the EOBs, you may call the toll-free ‍‍number on your ID card to request them. You can also view and print all of your EOBs online at www.myuhc.com. See Section 14, Glossary for the definition of Explanation of Benefits.

Important - Timely Filing of Non-Network Claims

All claim forms for non-Network services must be submitted within 12 months after the date of service. Otherwise, the Plan will not pay any Benefits for that Eligible Expense, or Benefits will be reduced, as determined by ‍‍Vermilion Parish School Board. This 12-month requirement does not apply if you are legally incapacitated. If your claim relates to an Inpatient Stay, the date of service is the date your Inpatient Stay ends.

Claim Denials and Appeals

If Your Claim is Denied

If a claim for Benefits is denied in part or in whole, you may call UnitedHealthcare at the ‍‍number on your ID card before requesting a formal appeal. If UnitedHealthcare cannot resolve the issue to your satisfaction over the phone, you have the right to file a formal appeal as described below.

How to Appeal a Denied Claim

If you wish to appeal a denied pre-service request for Benefits, post-service claim or a rescission of coverage as described below, you or your authorized representative must submit your appeal‍ in writing within 180 days of receiving the adverse benefit determination. You do not need to submit Urgent Care appeals in writing. This communication should include:

      the patient's name and ID number as shown on the ID card;

      the provider's name;

      the date of medical service;

      the reason you disagree with the denial; and

      any documentation or other written information to support your request.

You or your authorized representative may send a written request for an appeal to:

UnitedHealthcare‍ - Appeals
P.O. Box 30432
Salt Lake City, Utah 84130-0432

For Urgent Care requests for Benefits that have been denied, you or your provider can call UnitedHealthcare at the toll-free ‍‍number on your ID card to request an appeal.

Types of claims

The timing of the claims appeal process is based on the type of claim you are appealing. If you wish to appeal a claim, it helps to understand whether it is an:

      urgent care request for Benefits;

      pre-service request for Benefits;

      post-service claim; or

      concurrent claim.

Review of an Appeal

‍‍UnitedHealthcare will conduct a full and fair review of your appeal. The appeal may be reviewed by:

      an appropriate individual(s) who did not make the initial benefit determination; and

      a health care professional with appropriate expertise who was not consulted during the initial benefit determination process.

Once the review is complete, if UnitedHealthcare upholds the denial, you will receive a written explanation of the reasons and facts relating to the denial.

Filing a Second Appeal

Your ‍Plan offers two levels of appeal. If you are not satisfied with the first level appeal decision, you have the right to request a second level appeal from ‍‍Vermilion Parish School Board within 60 days from receipt of the first level appeal determination.

Note: Upon written request and free of charge, any Covered Persons may examine documents relevant to their claim and/or appeals and submit opinions and comments. ‍‍Vermilion Parish School Board will review all claims in accordance with the rules established by the U.S. Department of Labor.

Federal External Review Program

If, after exhausting your internal appeals, you are not satisfied with the determination made by ‍‍Vermilion Parish School Board, or if ‍‍Vermilion Parish School Board fails to respond to your appeal in accordance with applicable regulations regarding timing, you may be entitled to request an external review of ‍‍Vermilion Parish School Board's determination. The process is available at no charge to you.

If one of the above conditions is met, you may request an external review of adverse benefit determinations based upon any of the following:

      clinical reasons;

      the exclusions for Experimental or Investigational Services or Unproven Services;

      rescission of coverage (coverage that was cancelled or discontinued retroactively); or

      as otherwise required by applicable law.

You or your representative may request a standard external review by sending a written request to the address set out in the determination letter. You or your representative may request an expedited external review, in urgent situations as detailed below, by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. A request must be made within four months after the date you received ‍‍Vermilion Parish School Board's decision.

An external review request should include all of the following:

      a specific request for an external review;

      the Covered Person's name, address, and insurance ID number;

      your designated representative's name and address, when applicable;

      the service that was denied; and

      any new, relevant information that was not provided during the internal appeal.

An external review will be performed by an Independent Review Organization (IRO). UnitedHealthcare has entered into agreements with three or more IROs that have agreed to perform such reviews. There are two types of external reviews available:

      a standard external review; and

      an expedited external review.

Standard External Review

A standard external review is comprised of all of the following:

      a preliminary review by UnitedHealthcare of the request;

      a referral of the request by UnitedHealthcare to the IRO; and

      a decision by the IRO.

Within the applicable timeframe after receipt of the request, UnitedHealthcare will complete a preliminary review to determine whether the individual for whom the request was submitted meets all of the following:

      is or was covered under the Plan at the time the health care service or procedure that is at issue in the request was provided;

      has exhausted the applicable internal appeals process; and

      has provided all the information and forms required so that UnitedHealthcare may process the request.

After UnitedHealthcare completes the preliminary review, UnitedHealthcare will issue a notification in writing to you. If the request is eligible for external review, UnitedHealthcare will assign an IRO to conduct such review. UnitedHealthcare will assign requests by either rotating claims assignments among the IROs or by using a random selection process.

The IRO will notify you in writing of the request's eligibility and acceptance for external review. You may submit in writing to the IRO within ten business days following the date of receipt of the notice additional information that the IRO will consider when conducting the external review. The IRO is not required to, but may, accept and consider additional information submitted by you after ten business days.

UnitedHealthcare will provide to the assigned IRO the documents and information considered in making ‍‍Vermilion Parish School Board's determination. The documents include:

      all relevant medical records;

      all other documents relied upon by ‍‍Vermilion Parish School Board; and

      all other information or evidence that you or your Physician submitted. If there is any information or evidence you or your Physician wish to submit that was not previously provided, you may include this information with your external review request and UnitedHealthcare will include it with the documents forwarded to the IRO.

In reaching a decision, the IRO will review the claim anew and not be bound by any decisions or conclusions reached by ‍‍Vermilion Parish School Board. The IRO will provide written notice of its determination (the “Final External Review Decision”) within 45 days after it receives the request for the external review (unless they request additional time and you agree). The IRO will deliver the notice of Final External Review Decision to you and UnitedHealthcare, and it will include the clinical basis for the determination.

Upon receipt of a Final External Review Decision reversing ‍‍Vermilion Parish School Board determination, the Plan will immediately provide coverage or payment for the benefit claim at issue in accordance with the terms and conditions of the Plan, and any applicable law regarding plan remedies. If the Final External Review Decision is that payment or referral will not be made, the Plan will not be obligated to provide Benefits for the health care service or procedure.

Expedited External Review

An expedited external review is similar to a standard external review. The most significant difference between the two is that the time periods for completing certain portions of the review process are much shorter, and in some instances you may file an expedited external review before completing the internal appeals process.

You may make a written or verbal request for an expedited external review if you receive either of the following:

      an adverse benefit determination of a claim or appeal if the adverse benefit determination involves a medical condition for which the time frame for completion of an expedited internal appeal would seriously jeopardize the life or health of the individual or would jeopardize the individual's ability to regain maximum function and you have filed a request for an expedited internal appeal; or

      a final appeal decision, if the determination involves a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the individual or would jeopardize the individual's ability to regain maximum function, or if the final appeal decision concerns an admission, availability of care, continued stay, or health care service, procedure or product for which the individual received emergency services, but has not been discharged from a facility.

Immediately upon receipt of the request, UnitedHealthcare will determine whether the individual meets both of the following:

      is or was covered under the Plan at the time the health care service or procedure that is at issue in the request was provided.

      has provided all the information and forms required so that UnitedHealthcare may process the request.

After UnitedHealthcare completes the review, UnitedHealthcare will immediately send a notice in writing to you. Upon a determination that a request is eligible for expedited external review, UnitedHealthcare will assign an IRO in the same manner UnitedHealthcare utilizes to assign standard external reviews to IROs. UnitedHealthcare will provide all necessary documents and information considered in making the adverse benefit determination or final adverse benefit determination to the assigned IRO electronically or by telephone or facsimile or any other available expeditious method. The IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the same type of information and documents considered in a standard external review.

In reaching a decision, the IRO will review the claim anew and not be bound by any decisions or conclusions reached by ‍‍Vermilion Parish School Board. The IRO will provide notice of the final external review decision for an expedited external review as expeditiously as the claimant's medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request. If the initial notice is not in writing, within 48 hours after the date of providing the initial notice, the assigned IRO will provide written confirmation of the decision to you and to UnitedHealthcare.

You may contact UnitedHealthcare at the toll-free ‍‍number on your ID card for more information regarding external review rights, or if making a verbal request for an expedited external review.

Timing of Appeals Determinations

Separate schedules apply to the timing of claims appeals, depending on the type of claim. There are three types of claims:

      Urgent Care request for Benefits - a request for Benefits provided in connection with Urgent Care services, as defined in Section 14, Glossary;

      Pre-Service request for Benefits - a request for Benefits which the Plan must approve or in which you must notify UnitedHealthcare before non-Urgent Care is provided; and

      Post-Service - a claim for reimbursement of the cost of non-Urgent Care that has already been provided.

The tables below describe the time frames which you and UnitedHealthcare are required to follow.

Urgent Care Request for Benefits*

Type of Request for Benefits or Appeal

Timing

If your request for Benefits is incomplete, UnitedHealthcare must notify you within:

24 hours

You must then provide completed request for Benefits to UnitedHealthcare within:

48 hours after receiving notice of additional information required

UnitedHealthcare must notify you of the benefit determination within:

72 hours

If UnitedHealthcare denies your request for Benefits, you must appeal an adverse benefit determination no later than:

180 days after receiving the adverse benefit determination

UnitedHealthcare must notify you of the appeal decision within:

72 hours after receiving the appeal

*You do not need to submit Urgent Care appeals in writing. You should call UnitedHealthcare as soon as possible to appeal an Urgent Care request for Benefits.

 

Pre-Service Request for Benefits

Type of Request for Benefits or Appeal

Timing

If your request for Benefits is filed improperly, UnitedHealthcare must notify you within:

5 days

If your request for Benefits is incomplete, UnitedHealthcare must notify you within:

15 days

You must then provide completed request for Benefits information to UnitedHealthcare within:

45 days

UnitedHealthcare must notify you of the benefit determination:

      if the initial request for Benefits is complete, within:

15 days

      after receiving the completed request for Benefits (if the initial request for Benefits is incomplete), within:

15 days

You must appeal an adverse benefit determination no later than:

180 days after receiving the adverse benefit determination

UnitedHealthcare must notify you of the first level appeal decision within:

15 days after receiving the first level appeal

You must appeal the first level appeal (file a second level appeal) within:

60 days after receiving the first level appeal decision

Vermilion Parish School Board must notify you of the second level appeal decision within:

15 days after receiving the second level appeal

 


Post-Service Claims

Type of Claim or Appeal

Timing

If your claim is incomplete, UnitedHealthcare must notify you within:

30 days

You must then provide completed claim information to UnitedHealthcare within:

45 days

UnitedHealthcare must notify you of the benefit determination:

      if the initial claim is complete, within:

30 days

      after receiving the completed claim (if the initial claim is incomplete), within:

30 days

You must appeal an adverse benefit determination no later than:

180 days after receiving the adverse benefit determination

UnitedHealthcare must notify you of the first level appeal decision within:

30 days after receiving the first level appeal

You must appeal the first level appeal (file a second level appeal) within:

60 days after receiving the first level appeal decision

Vermilion Parish School Board must notify you of the second level appeal decision within:

30 days after receiving the second level appeal

Concurrent Care Claims

If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an Urgent Care request for Benefits as defined above, your request will be decided within 24 hours, provided your request is made at least 24 hours prior to the end of the approved treatment. UnitedHealthcare will make a determination on your request for the extended treatment within 24 hours from receipt of your request.

If your request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the request will be treated as an Urgent Care request for Benefits and decided according to the timeframes described above. If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and you request to extend treatment in a non-urgent circumstance, your request will be considered a new request and decided according to post-service or pre-service timeframes, whichever applies.

Limitation of Action

You cannot bring any legal action against Vermilion Parish School Board or the Claims Administrator to recover reimbursement until 90 days after you have properly submitted a request for reimbursement as described in this section and all required reviews of your claim have been completed. If you want to bring a legal action against Vermilion Parish School Board or the Claims Administrator, you must do so within three years from the expiration of the time period in which a request for reimbursement must be submitted or you lose any rights to bring such an action against Vermilion Parish School Board or the Claims Administrator.

You cannot bring any legal action against Vermilion Parish School Board or the Claims Administrator for any other reason unless you first complete all the steps in the appeal process described in this section. After completing that process, if you want to bring a legal action against Vermilion Parish School Board or the Claims Administrator you must do so within three years of the date you are notified of the final decision on your appeal or you lose any rights to bring such an action against Vermilion Parish School Board or the Claims Administrator.


SECTION 10 - COORDINATION OF BENEFITS (COB)

What this section includes:

      How your Benefits under this Plan coordinate with other medical plans;

      How coverage is affected if you become eligible for Medicare; and

      Procedures in the event the Plan overpays Benefits.

Coordination of Benefits (COB) applies to you if you are covered by more than one health benefits plan, including any one of the following:

      another employer sponsored health benefits plan;

      a medical component of a group long-term care plan, such as skilled nursing care;

      no-fault or traditional "fault" type medical payment benefits or personal injury protection benefits under an auto insurance policy;

      medical payment benefits under any premises liability or other types of liability coverage; or

      Medicare or other governmental health benefit.

If coverage is provided under two or more plans, COB determines which plan is primary and which plan is secondary. The plan considered primary pays its benefits first, without regard to the possibility that another plan may cover some expenses. Any remaining expenses may be paid under the other plan, which is considered secondary. The secondary plan may determine its benefits based on the benefits paid by the primary plan.

Don't forget to update your Dependents' Medical Coverage Information

Avoid delays on your Dependent claims by updating your Dependent's medical coverage information. Just log on to www.myuhc.comor call the toll-free ‍‍number on your ID card to update your COB information. You will need the name of your Dependent's other medical coverage, along with the policy number.

Determining Which Plan is Primary

If you are covered by two or more plans, the benefit payment follows the rules below in this order:

      this Plan will always be secondary to medical payment coverage or personal injury protection coverage under any auto liability or no-fault insurance policy;

      when you have coverage under two or more medical plans and only one has COB provisions, the plan without COB provisions will pay benefits first;

      a plan that covers a person as an employee pays benefits before a plan that covers the person as a dependent;

      if you are receiving COBRA continuation coverage under another employer plan, this Plan will pay Benefits first;

      your dependent children will receive primary coverage from the parent whose birth date occurs first in a calendar year. If both parents have the same birth date, the plan that pays benefits first is the one that has been in effect the longest. This birthday rule applies only if:

-        the parents are married or living together whether or not they have ever been married and not legally separated; or

-        a court decree awards joint custody without specifying that one party has the responsibility to provide health care coverage;

      if two or more plans cover a dependent child of divorced or separated parents and if there is no court decree stating that one parent is responsible for health care, the child will be covered under the plan of:

-        the parent with custody of the child; then

-        the Spouse of the parent with custody of the child; then

-        the parent not having custody of the child; then

-        the Spouse of the parent not having custody of the child;

      plans for active employees pay before plans covering laid-off or retired employees;

      the plan that has covered the individual claimant the longest will pay first; and

      finally, if none of the above rules determines which plan is primary or secondary, the allowable expenses shall be shared equally between the plans meeting the definition of Plan. In addition, this Plan will not pay more than it would have paid had it been the primary Plan.

The following examples illustrate how the Plan determines which plan pays first and which plan pays second.

Determining Primary and Secondary Plan – Examples

1) Let's say you and your Spouse both have family medical coverage through your respective employers. You are unwell and go to see a Physician. Since you're covered as an Employee under this Plan, and as a Dependent under your Spouse's plan, this Plan will pay Benefits for the Physician's office visit first.

2) Again, let's say you and your Spouse both have family medical coverage through your respective employers. You take your Dependent child to see a Physician. This Plan will look at your birthday and your Spouse's birthday to determine which plan pays first. If you were born on June 11 and your Spouse was born on May 30, your Spouse's plan will pay first.

When This Plan is Secondary

If this Plan is secondary‍, it determines the amount it will pay for a Covered Health Service by following the steps below.

      the Plan determines the amount it would have paid based on the allowable expense.

      the Plan pays the entire difference between the allowable expense and the amount paid by the primary plan – as long as this amount is not more than the Plan would have paid had it been the only plan involved.

You will be responsible for any Copay, Coinsurance or Deductible payments as part of the COB payment. The maximum combined payment you may receive from all plans cannot exceed 100% of the total allowable expense. See the textbox below for the definition of allowable expense.

Determining the Allowable Expense If This Plan is Secondary

If this Plan is secondary, the allowable expense is the primary plan's Network rate. If the primary plan bases its reimbursement on reasonable and customary charges, the allowable expense is the primary plan's reasonable and customary charge. If both the primary plan and this Plan do not have a contracted rate, the allowable expense will be the greater of the two plans’ reasonable and customary charges.

When the provider is a Network provider for both the primary plan and this Plan, the allowable expense is the primary plan’s network rate. When the provider is a network provider for the primary plan and a non-Network provider for this Plan, the allowable expense is the primary plan’s network rate. When the provider is a non-Network provider for the primary plan and a Network provider for this Plan, the allowable expense is the reasonable and customary charges allowed by the primary plan. When the provider is a non-Network provider for both the primary plan and this Plan, the allowable expense is the greater of the two Plans’ reasonable and customary charges.

What is an allowable expense?

For purposes of COB, an allowable expense is a health care expense that is covered at least in part by one of the health benefit plans covering you.

When a Covered Person Qualifies for Medicare

Determining Which Plan is Primary

To the extent permitted by law, this Plan will pay Benefits second to Medicare when you become eligible for Medicare, even if you don't elect it. There are, however, Medicare-eligible individuals for whom the Plan pays Benefits first and Medicare pays benefits second:

      Employees with active current employment status age 65 or older and their Spouses age 65 or older (however, Domestic Partners are excluded as provided by Medicare); and

      individuals with end-stage renal disease, for a limited period of time.

Determining the Allowable Expense When This Plan is Secondary to Medicare

If this Plan is secondary to Medicare, the Medicare approved amount is the allowable expense, as long as the provider accepts Medicare. If the provider does not accept Medicare, the Medicare limiting charge (the most a provider can charge you if they don't accept Medicare) will be the allowable expense. Medicare payments, combined with Plan Benefits, will not exceed 100% of the total allowable expense.

If you are eligible for, but not enrolled in, Medicare, and this Plan is secondary to Medicare, Benefits payable under this Plan will be reduced by the amount that would have been paid if you had been enrolled in Medicare.

Right to Receive and Release Needed Information

Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under this Plan and other plans. UnitedHealthcare may get the facts needed from, or give them to, other organizations or persons for the purpose of applying these rules and determining benefits payable under this Plan and other plans covering the person claiming benefits.

UnitedHealthcare does not need to tell, or get the consent of, any person to do this. Each person claiming benefits under this Plan must give UnitedHealthcare any facts needed to apply those rules and determine benefits payable. If you do not provide UnitedHealthcare the information needed to apply these rules and determine the Benefits payable, your claim for Benefits will be denied.

Overpayment and Underpayment of Benefits

If you are covered under more than one medical plan, there is a possibility that the other plan will pay a benefit that UnitedHealthcare should have paid. If this occurs, the Plan may pay the other plan the amount owed.

If the Plan pays you more than it owes under this COB provision, you should pay the excess back promptly. Otherwise, the Company may recover the amount in the form of salary, wages, or benefits payable under any Company-sponsored benefit plans, including this Plan. The Company also reserves the right to recover any overpayment by legal action or offset payments on future Eligible Expenses.

If the Plan overpays a health care provider, UnitedHealthcare reserves the right to recover the excess amount, by legal action if necessary.

Refund of Overpayments

If Vermilion Parish School Board pays for Benefits for expenses incurred on account of a Covered Person, that Covered Person, or any other person or organization that was paid, must make a refund to Vermilion Parish School Board if:

      all or some of the expenses were not paid by the Covered Person or did not legally have to be paid by the Covered Person;

      all or some of the payment Vermilion Parish School Board made exceeded the Benefits under the Plan; or

      all or some of the payment was made in error.

The refund equals the amount Vermilion Parish School Board paid in excess of the amount that should have been paid under the Plan. If the refund is due from another person or organization, the Covered Person agrees to help Vermilion Parish School Board get the refund when requested.

If the Covered Person, or any other person or organization that was paid, does not promptly refund the full amount, Vermilion Parish School Board may reduce the amount of any future Benefits for the Covered Person that are payable under the Plan. The reductions will equal the amount of the required refund. Vermilion Parish School Board may have other rights in addition to the right to reduce future Benefits.


SECTION 11 - SUBROGATION AND REIMBURSEMENT

What this section includes:

      How your Benefits are impacted if you suffer a Sickness or Injury caused by a third party.

The Plan has a right to subrogation and reimbursement.

Subrogation applies when the plan has paid Benefits on your behalf for a Sickness or Injury for which a third party is alleged to be responsible. The right to subrogation means that the Plan is substituted to and shall succeed to any and all legal claims that you may be entitled to pursue against any third party for the Benefits that the Plan has paid that are related to the Sickness or Injury for which a third party is alleged to be responsible.

Subrogation – Example

Suppose you are injured in a car accident that is not your fault, and you receive Benefits under the Plan to treat your injuries. Under subrogation, the Plan has the right to take legal action in your name against the driver who caused the accident and that driver's insurance carrier to recover the cost of those Benefits.

The right to reimbursement means that if a third party causes or is alleged to have caused a Sickness or Injury for which you receive a settlement, judgment, or other recovery from any third party, you must use those proceeds to fully return to the Plan 100% of any Benefits you received for that Sickness or Injury.

Reimbursement – Example

Suppose you are injured in a boating accident that is not your fault, and you receive Benefits under the Plan as a result of your injuries. In addition, you receive a settlement in a court proceeding from the individual who caused the accident. You must use the settlement funds to return to the plan 100% of any Benefits you received to treat your injuries.

The following persons and entities are considered third parties:

      a person or entity alleged to have caused you to suffer a Sickness, Injury or damages, or who is legally responsible for the Sickness, Injury or damages;

      any insurer or other indemnifier of any person or entity alleged to have caused or who caused the Sickness, Injury or damages;

      the Plan Sponsor (for example workers’ compensation cases);

      any person or entity who is or may be obligated to provide benefits or payments to you, including benefits or payments for underinsured or uninsured motorist protection, no-fault or traditional auto insurance, medical payment coverage (auto, homeowners or otherwise), workers' compensation coverage, other insurance carriers or third party administrators; and

      any person or entity that is liable for payment to you on any equitable or legal liability theory.

You agree as follows:

        You will cooperate with the Plan in protecting its legal and equitable rights to subrogation and reimbursement in a timely manner, including, but not limited to:

-         notifying the Plan, in writing, of any potential legal claim(s) you may have against any third party for acts which caused Benefits to be paid or become payable;

-         providing any relevant information requested by the Plan;

-         signing and/or delivering such documents as the Plan or its agents reasonably request to secure the subrogation and reimbursement claim;

-         responding to requests for information about any accident or injuries;

-         making court appearances;

-         obtaining the Plan’s consent or its agents' consent before releasing any party from liability or payment of medical expenses; and

-         complying with the terms of this section.

Your failure to cooperate with the Plan is considered a breach of contract. As such, the Plan has the right to terminate your Benefits, deny future Benefits, take legal action against you, and/or set off from any future Benefits the value of Benefits the Plan has paid relating to any Sickness or Injury alleged to have been caused or caused by any third party to the extent not recovered by the Plan due to you or your representative not cooperating with the Plan. If the Plan incurs attorneys' fees and costs in order to collect third party settlement funds held by you or your representative, the Plan has the right to recover those fees and costs from you.  You will also be required to pay interest on any amounts you hold which should have been returned to the Plan.

      The Plan has a first priority right to receive payment on any claim against a third party before you receive payment from that third party.  Further, the Plan’s first priority right to payment is superior to any and all claims, debts or liens asserted by any medical providers, including but not limited to Hospitals or emergency treatment facilities, that assert a right to payment from funds payable from or recovered from an allegedly responsible third party and/or insurance carrier. 

      The Plan’s subrogation and reimbursement rights apply to full and partial settlements, judgments, or other recoveries paid or payable to you or your representative, no matter how those proceeds are captioned or characterized. Payments include, but are not limited to, economic, non-economic, and punitive damages. The Plan is not required to help you to pursue your claim for damages or personal injuries and no amount of associated costs, including attorneys’ fees, shall be deducted from the Plan’s recovery without the Plan’s express written consent.  No so-called “Fund Doctrine” or “Common Fund Doctrine” or “Attorney’s Fund Doctrine” shall defeat this right.

      Regardless of whether you have been fully compensated or made whole, the Plan may collect from you the proceeds of any full or partial recovery that you or your legal representative obtain, whether in the form of a settlement (either before or after any determination of liability) or judgment, no matter how those proceeds are captioned or characterized. Proceeds from which the Plan may collect include, but are not limited to, economic, non-economic, and punitive damages. No "collateral source" rule, any “Made-Whole Doctrine” or “Make-Whole Doctrine,” claim of unjust enrichment, nor any other equitable limitation shall limit the Plan’s subrogation and reimbursement rights.

      Benefits paid by the Plan may also be considered to be Benefits advanced.

      If you receive any payment from any party as a result of Sickness or Injury, and the Plan alleges some or all of those funds are due and owed to the Plan, you shall hold those funds in trust, either in a separate bank account in your name or in your attorney's trust account. You agree that you will serve as a trustee over those funds to the extent of the Benefits the Plan has paid.

      The Plan’s rights to recovery will not be reduced due to your own negligence.

      Upon the Plan’s request, you will assign to the Plan all rights of recovery against third parties, to the extent of the Benefits the Plan has paid for the Sickness or Injury.

      The Plan may, at its option, take necessary and appropriate action to preserve its rights under these subrogation provisions, including but not limited to, providing or exchanging medical payment information with an insurer, the insurer’s legal representative or other third party and filing suit in your name, which does not obligate the Plan in any way to pay you part of any recovery the Plan might obtain.

      You may not accept any settlement that does not fully reimburse the Plan, without its written approval.

      The Plan has the authority and discretion to resolve all disputes regarding the interpretation of the language stated herein.

      In the case of your wrongful death or survival claim, the provisions of this section apply to your estate, the personal representative of your estate, and your heirs or beneficiaries.

      No allocation of damages, settlement funds or any other recovery, by you, your estate, the personal representative of your estate, your heirs, your beneficiaries or any other person or party, shall be valid if it does not reimburse the Plan for 100% of its interest unless the Plan provides written consent to the allocation.

      The provisions of this section apply to the parents, guardian, or other representative of a Dependent child who incurs a Sickness or Injury caused by a third party. If a parent or guardian may bring a claim for damages arising out of a minor's Sickness or Injury, the terms of this subrogation and reimbursement clause shall apply to that claim.

      If a third party causes or is alleged to have caused you to suffer a Sickness or Injury while you are covered under this Plan, the provisions of this section continue to apply, even after you are no longer covered.

      The Plan and all Administrators administering the terms and conditions of the Plan’s subrogation and reimbursement rights have such powers and duties as are necessary to discharge its duties and functions, including the exercise of its discretionary authority to (1) construe and enforce the terms of the Plan’s subrogation and reimbursement rights and (2) make determinations with respect to the subrogation amounts and reimbursements owed to the Plan.

Right of Recovery

The Plan has the right to recover benefits it has paid on you or your Dependent’s behalf that were:

      made in error;

      due to a mistake in fact;

      advanced during the time period of meeting the calendar year Deductible; or

      advanced during the time period of meeting the Out-of-Pocket Maximum for the calendar year.

Benefits paid because you or your Dependent misrepresented facts are also subject to recovery.

If the Plan provides a Benefit for you or your Dependent that exceeds the amount that should have been paid, the Plan will:

      require that the overpayment be returned when requested, or

      reduce a future benefit payment for you or your Dependent by the amount of the overpayment.

If the Plan provides an advancement of benefits to you or your Dependent during the time period of meeting the Deductible and/or meeting the Out-of-Pocket Maximum for the calendar year, the Plan will send you or your Dependent a monthly statement identifying the amount you owe with payment instructions. The Plan has the right to recover Benefits it has advanced by:

      submitting a reminder letter to you or a covered Dependent that details any outstanding balance owed to the Plan; and

      conducting courtesy calls to you or a covered Dependent to discuss any outstanding balance owed to the Plan.


SECTION 12 - WHEN COVERAGE ENDS

What this section includes:

      Circumstances that cause coverage to end;‍

      Extended coverage; and

      How to continue coverage after it ends.

Your entitlement to Benefits automatically ends on the date that coverage ends, even if you are hospitalized or are otherwise receiving medical treatment on that date. Please note that this does not affect coverage that is extended under Extended Coverage for Total Disability below.

When your coverage ends, Vermilion Parish School Board will still pay claims for Covered Health Services that you received before your coverage ended. However, once your coverage ends, Benefits are not provided for health services that you receive after coverage ended, even if the underlying medical condition occurred before your coverage ended. Please note that this does not affect coverage that is extended under Extended Coverage for Total Disability below.

Your coverage under the Plan will end on the earliest of:

      the last day of the month your employment with the Company ends;

      the date the Plan ends;

      the last day of the month you stop making the required contributions;

      the last day of the month you are no longer eligible;

      the last day of the month UnitedHealthcare receives written notice from Vermilion Parish School Board to end your coverage, or the date requested in the notice, if later; or

      the last day of the month you retire or are pensioned under the Plan, unless specific coverage is available for retired or pensioned persons and you are eligible for that coverage.

Coverage for your eligible Dependents will end on the earliest of:

      the date your coverage ends;

      the last day of the month you stop making the required contributions;

      the last day of the month UnitedHealthcare receives written notice from Vermilion Parish School Board to end your coverage, or the date requested in the notice, if later; or

      the last day of the month your Dependents no longer qualify as Dependents under this Plan.

Other Events Ending Your Coverage

The Plan will provide prior written notice to you that your coverage will end on the date identified in the notice if:

      you commit an act, practice, or omission that constituted fraud, or an intentional misrepresentation of a material fact including, but not limited to, false information relating to another person's eligibility or status as a Dependent; or

      you commit an act of physical or verbal abuse that imposes a threat to Vermilion Parish School Board's staff, UnitedHealthcare's staff, a provider or another Covered Person.

Note: Vermilion Parish School Board has the right to demand that you pay back Benefits Vermilion Parish School Board paid to you, or paid in your name, during the time you were incorrectly covered under the Plan.

Coverage for a Disabled Child

If an unmarried enrolled Dependent child with a mental or physical disability reaches an age when coverage would otherwise end, the Plan will continue to cover the child, as long as:

      the child is unable to be self-supporting due to a mental or physical handicap or disability;

      the child depends mainly on you for support;

      you provide to Vermilion Parish School Board proof of the child's incapacity and dependency within 31 days of the date coverage would have otherwise ended because the child reached a certain age; and

      you provide proof, upon Vermilion Parish School Board's request, that the child continues to meet these conditions.

The proof might include medical examinations at Vermilion Parish School Board's expense. However, you will not be asked for this information more than once a year. If you do not supply such proof within 31 days, the Plan will no longer pay Benefits for that child.

Coverage will continue, as long as the enrolled Dependent is incapacitated and dependent upon you, unless coverage is otherwise terminated in accordance with the terms of the Plan.

Extended Coverage for Total Disability

If a Covered Person has a Total Disability on the date their coverage under the Plan ends, their Benefits will not end automatically. The Plan will temporarily extend coverage, only for treatment of the condition causing the Total Disability. Benefits will be paid until the earlier of:

      the Total Disability ends; or

      twelve months from the date coverage would have ended.

Continuing Coverage Through COBRA

If you lose your Plan coverage, you may have the right to extend it under the Consolidated Budget Reconciliation Act of 1985 (COBRA), as defined in Section 14, Glossary.

Continuation coverage under COBRA is available only to Plans that are subject to the terms of COBRA. You can contact your Plan Administrator to determine if Vermilion Parish School Board is subject to the provisions of COBRA.

Continuation Coverage under Federal Law (COBRA)

Much of the language in this section comes from the federal law that governs continuation coverage. You should call your Plan Administrator if you have questions about your right to continue coverage.

In order to be eligible for continuation coverage under federal law, you must meet the definition of a "Qualified Beneficiary". A Qualified Beneficiary is any of the following persons who were covered under the Plan on the day before a qualifying event:

      an Employee;

      an Employee's enrolled Dependent, including with respect to the Employee's children, a child born to or placed for adoption with the Employee during a period of continuation coverage under federal law; or

      an Employee's former Spouse.

Qualifying Events for Continuation Coverage under COBRA

The following table outlines situations in which you may elect to continue coverage under COBRA for yourself and your Dependents, and the maximum length of time you can receive continued coverage. These situations are considered qualifying events.

If Coverage Ends Because of the Following Qualifying Events:

You May Elect COBRA:

For Yourself

For Your Spouse

For Your Child(ren)

Your work hours are reduced

18 months

18 months

18 months

Your employment terminates for any reason (other than gross misconduct)

18 months

18 months

18 months

You or your family member become eligible for Social Security disability benefits at any time within the first 60 days of losing coverage1

29 months

29 months

29 months

You die

N/A

36 months

36 months

You divorce (or legally separate)

N/A

36 months

36 months

Your child is no longer an eligible family member (e.g., reaches the maximum age limit)

N/A

N/A

36 months

You become entitled to Medicare

N/A

See table below

See table below

Vermilion Parish School Board files for bankruptcy under Title 11, United States Code.2

36 months

36 months3

36 months3

1Subject to the following conditions: (i) notice of the disability must be provided within the latest of 60 days after a). the determination of the disability, b). the date of the qualifying event, c). the date the Qualified Beneficiary would lose coverage under the Plan, and in no event later than the end of the first 18 months; (ii) the Qualified Beneficiary must agree to pay any increase in the required premium for the additional 11 months over the original 18 months; and (iii) if the Qualified Beneficiary entitled to the 11 months of coverage has non-disabled family members who are also Qualified Beneficiaries, then those non-disabled Qualified Beneficiaries are also entitled to the additional 11 months of continuation coverage. Notice of any final determination that the Qualified Beneficiary is no longer disabled must be provided within 30 days of such determination. Thereafter, continuation coverage may be terminated on the first day of the month that begins more than 30 days after the date of that determination.

2This is a qualifying event for any Retired Employee and his or her enrolled Dependents if there is a substantial elimination of coverage within one year before or after the date the bankruptcy was filed.

3From the date of the Employee's death if the Employee dies during the continuation coverage.

How Your Medicare Eligibility Affects Dependent COBRA Coverage

The table below outlines how your Dependents' COBRA coverage is impacted if you become entitled to Medicare.

If Dependent Coverage Ends When:

You May Elect COBRA Dependent Coverage For Up To:

You become entitled to Medicare and don't experience any additional qualifying events

18 months

You become entitled to Medicare, after which you experience a second qualifying event* before the initial 18-month period expires

36 months

You experience a qualifying event*, after which you become entitled to Medicare before the initial 18-month period expires; and, if absent this initial qualifying event, your Medicare entitlement would have resulted in loss of Dependent coverage under the Plan

36 months

* Your work hours are reduced or your employment is terminated for reasons other than gross misconduct.

Getting Started

You will be notified by mail if you become eligible for COBRA coverage as a result of a reduction in work hours or termination of employment. The notification will give you instructions for electing COBRA coverage, and advise you of the monthly cost. Your monthly cost is the full cost, including both Employee and Employer costs, plus a 2% administrative fee or other cost as permitted by law.

You will have up to 60 days from the date you receive notification or 60 days from the date your coverage ends to elect COBRA coverage, whichever is later. You will then have an additional 45 days to pay the cost of your COBRA coverage, retroactive to the date your Plan coverage ended.

During the 60-day election period, the Plan will, only in response to a request from a provider, inform that provider of your right to elect COBRA coverage, retroactive to the date your COBRA eligibility began.

While you are a participant in the medical Plan under COBRA, you have the right to change your coverage election:

      during Open Enrollment; and

      following a change in family status, as described under Changing Your Coverage in Section 2, Introduction.

Notification Requirements

If your covered Dependents lose coverage due to divorce, legal separation, or loss of Dependent status, you or your Dependents must notify the Plan Administrator within 60 days of the latest of:

      the date of the divorce, legal separation or an enrolled Dependent's loss of eligibility as an enrolled Dependent;

      the date your enrolled Dependent would lose coverage under the Plan; or

      the date on which you or your enrolled Dependent are informed of your obligation to provide notice and the procedures for providing such notice.

You or your Dependents must also notify the Plan Administrator when a qualifying event occurs that will extend continuation coverage.

If you or your Dependents fail to notify the Plan Administrator of these events within the 60 day period, the Plan Administrator is not obligated to provide continued coverage to the affected Qualified Beneficiary. If you are continuing coverage under federal law, you must notify the Plan Administrator within 60 days of the birth or adoption of a child.

Once you have notified the Plan Administrator, you will then be notified by mail of your election rights under COBRA.

Notification Requirements for Disability Determination

If you extend your COBRA coverage beyond 18 months because you are eligible for disability benefits from Social Security, you must provide ‍‍the Benefits Department with notice of the Social Security Administration's determination within 60 days after you receive that determination, and before the end of your initial 18-month continuation period.

The notice requirements will be satisfied by providing written notice to the Plan Administrator at the address stated in Section 16, Important Administrative Information: ERISA. The contents of the notice must be such that the Plan Administrator is able to determine the covered Employee and qualified beneficiary(ies), the qualifying event or disability, and the date on which the qualifying event occurred.

Trade Act of 2002

The Trade Act of 2002 amended COBRA to provide for a special second 60-day COBRA election period for certain Employees who have experienced a termination or reduction of hours and who lose group health plan coverage as a result. The special second COBRA election period is available only to a very limited group of individuals: generally, those who are receiving trade adjustment assistance (TAA) or 'alternative trade adjustment assistance' under a federal law called the Trade Act of 1974. These Employees are entitled to a second opportunity to elect COBRA coverage for themselves and certain family members (if they did not already elect COBRA coverage), but only within a limited period of 60 days from the first day of the month when an individual begins receiving TAA (or would be eligible to receive TAA but for the requirement that unemployment benefits be exhausted) and only during the six months immediately after their group health plan coverage ended.

If an Employee qualifies or may qualify for assistance under the Trade Act of 1974, he or she should contact the Plan Administrator for additional information. The Employee must contact the Plan Administrator promptly after qualifying for assistance under the Trade Act of 1974 or the Employee will lose his or her special COBRA rights. COBRA coverage elected during the special second election period is not retroactive to the date that Plan coverage was lost, but begins on the first day of the special second election period.

When COBRA Ends

COBRA coverage will end before the maximum continuation period shown above if:

      you or your covered Dependent becomes covered under another group medical plan, as long as the other plan doesn't limit your coverage due to a preexisting condition; or if the other plan does exclude coverage due to your preexisting condition, your COBRA benefits would end when the exclusion period ends;

      you or your covered Dependent becomes entitled to, and enrolls in, Medicare after electing COBRA;

      the first required premium is not paid within 45 days;

      any other monthly premium is not paid within 30 days of its due date;

      the entire Plan ends; or

      coverage would otherwise terminate under the Plan as described in the beginning of this section.

Note: If you selected continuation coverage under a prior plan which was then replaced by coverage under this Plan, continuation coverage will end as scheduled under the prior plan or in accordance with the terminating events listed in this section, whichever is earlier.

Uniformed Services Employment and Reemployment Rights Act

An Employee who is absent from employment for more than 30 days by reason of service in the Uniformed Services may elect to continue Plan coverage for the Employee and the Employee's Dependents in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended (USERRA).

The terms "Uniformed Services" or "Military Service" mean the Armed Forces, the Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps of the Public Health Service, and any other category of persons designated by the President in time of war or national emergency.

If qualified to continue coverage pursuant to the USERRA, Employees may elect to continue coverage under the Plan by notifying the Plan Administrator in advance, and providing payment of any required contribution for the health coverage. This may include the amount the Plan Administrator normally pays on an Employee's behalf. If an Employee's Military Service is for a period of time less than 31 days, the Employee may not be required to pay more than the regular contribution amount, if any, for continuation of health coverage.

An Employee may continue Plan coverage under USERRA for up to the lesser of:

      the 24 month period beginning on the date of the Employee's absence from work; or

      the day after the date on which the Employee fails to apply for, or return to, a position of employment.

Regardless of whether an Employee continues health coverage, if the Employee returns to a position of employment, the Employee's health coverage and that of the Employee's eligible Dependents will be reinstated under the Plan. No exclusions or waiting period may be imposed on an Employee or the Employee's eligible Dependents in connection with this reinstatement, unless a Sickness or Injury is determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the performance of military service.

You should call the Plan Administrator if you have questions about your rights to continue health coverage under USERRA.

 


SECTION 13 - OTHER IMPORTANT INFORMATION

What this section includes:

      Court-ordered Benefits for Dependent children;

      Your relationship with UnitedHealthcare and Vermilion Parish School Board;

      Relationships with providers;

      Interpretation of Benefits;

      Information and records;

      Incentives to providers and you;

      The future of the Plan; and

      How to access the official Plan documents.

Qualified Medical Child Support Orders (QMCSOs)

A qualified medical child support order (QMCSO) is a judgment, decree or order issued by a court or appropriate state agency that requires a child to be covered for medical benefits. Generally, a QMCSO is issued as part of a paternity, divorce, or other child support settlement.

If the Plan receives a medical child support order for your child that instructs the Plan to cover the child, the Plan Administrator will review it to determine if it meets the requirements for a QMCSO. If it determines that it does, your child will be enrolled in the Plan as your Dependent, and the Plan will be required to pay Benefits as directed by the order.

You may obtain, without charge, a copy of the procedures governing QMCSOs from the Plan Administrator.

Note: A National Medical Support Notice will be recognized as a QMCSO if it meets the requirements of a QMCSO.

Your Relationship with UnitedHealthcare and Vermilion Parish School Board

In order to make choices about your health care coverage and treatment, Vermilion Parish School Board believes that it is important for you to understand how UnitedHealthcare interacts with the Plan Sponsor's benefit Plan and how it may affect you. UnitedHealthcare helps administer the Plan Sponsor's benefit plan in which you are enrolled. UnitedHealthcare does not provide medical services or make treatment decisions. This means:

      Vermilion Parish School Board and UnitedHealthcare do not decide what care you need or will receive. You and your Physician make those decisions;

      UnitedHealthcare communicates to you decisions about whether the Plan will cover or pay for the health care that you may receive (the Plan pays for Covered Health Services, which are more fully described in this SPD); and

      the Plan may not pay for all treatments you or your Physician may believe are necessary. If the Plan does not pay, you will be responsible for the cost.

Vermilion Parish School Board and UnitedHealthcare may use individually identifiable information about you to identify for you (and you alone) procedures, products or services that you may find valuable. Vermilion Parish School Board and UnitedHealthcare will use individually identifiable information about you as permitted or required by law, including in operations and in research. Vermilion Parish School Board and UnitedHealthcare will use de-identified data for commercial purposes including research.

Relationship with Providers

The relationships between Vermilion Parish School Board, UnitedHealthcare‍ and Network providers are solely contractual relationships between independent contractors. Network providers are not Vermilion Parish School Board's agents or employees, nor are they agents or employees of UnitedHealthcare‍. Vermilion Parish School Board and any of its employees are not agents or employees of Network providers, nor are UnitedHealthcare‍ and any of its employees agents or employees of Network providers.

Vermilion Parish School Board and UnitedHealthcare‍ do not provide health care services or supplies, nor do they practice medicine. Instead, Vermilion Parish School Board and UnitedHealthcare‍ arrange for health care providers to participate in a Network and pay Benefits. Network providers are independent practitioners who run their own offices and facilities. UnitedHealthcare's‍ credentialing process confirms public information about the providers' licenses and other credentials, but does not assure the quality of the services provided. They are not Vermilion Parish School Board's employees nor are they employees of UnitedHealthcare. Vermilion Parish School Board and UnitedHealthcare‍ do not have any other relationship with Network providers such as principal-agent or joint venture. Vermilion Parish School Board and UnitedHealthcare‍ are not liable for any act or omission of any provider.

UnitedHealthcare‍ is not considered to be an employer of the Plan Administrator for any purpose with respect to the administration or provision of benefits under this Plan.

Vermilion Parish School Board is solely responsible for:

      enrollment and classification changes (including classification changes resulting in your enrollment or the termination of your coverage);

      the timely payment of Benefits; and

      notifying you of the termination or modifications to the Plan.

Your Relationship with Providers

The relationship between you and any provider is that of provider and patient. Your provider is solely responsible for the quality of the services provided to you. You:

      are responsible for choosing your own provider;

      are responsible for paying, directly to your provider, any amount identified as a member responsibility, including Copayments, Coinsurance, any Annual Deductible and any amount that exceeds Eligible Expenses;

      are responsible for paying, directly to your provider, the cost of any non-Covered Health Service;

      must decide if any provider treating you is right for you (this includes Network providers you choose and providers to whom you have been referred); and

      must decide with your provider what care you should receive.

Interpretation of Benefits

Vermilion Parish School Board and UnitedHealthcare have the sole and exclusive discretion to:

      interpret Benefits under the Plan;

      interpret the other terms, conditions, limitations and exclusions of the Plan, including this SPD and any Riders and/or Amendments; and

      make factual determinations related to the Plan and its Benefits.

Vermilion Parish School Board and UnitedHealthcare may delegate this discretionary authority to other persons or entities that provide services in regard to the administration of the Plan.

In certain circumstances, for purposes of overall cost savings or efficiency, Vermilion Parish School Board may, in its discretion, offer Benefits for services that would otherwise not be Covered Health Services. The fact that Vermilion Parish School Board does so in any particular case shall not in any way be deemed to require Vermilion Parish School Board to do so in other similar cases.

Information and Records

Vermilion Parish School Board and UnitedHealthcare may use your individually identifiable health information to administer the Plan and pay claims, to identify procedures, products, or services that you may find valuable, and as otherwise permitted or required by law. Vermilion Parish School Board and UnitedHealthcare may request additional information from you to decide your claim for Benefits. Vermilion Parish School Board and UnitedHealthcare will keep this information confidential. Vermilion Parish School Board and UnitedHealthcare may also use your de-identified data for commercial purposes, including research, as permitted by law.

By accepting Benefits under the Plan, you authorize and direct any person or institution that has provided services to you to furnish Vermilion Parish School Board and UnitedHealthcare with all information or copies of records relating to the services provided to you. Vermilion Parish School Board and UnitedHealthcare have the right to request this information at any reasonable time. This applies to all Covered Persons, including enrolled Dependents whether or not they have signed the Employee's enrollment form. Vermilion Parish School Board and UnitedHealthcare agree that such information and records will be considered confidential.

Vermilion Parish School Board and UnitedHealthcare have the right to release any and all records concerning health care services which are necessary to implement and administer the terms of the Plan, for appropriate medical review or quality assessment, or as Vermilion Parish School Board is required to do by law or regulation. During and after the term of the Plan, Vermilion Parish School Board and UnitedHealthcare and its related entities may use and transfer the information gathered under the Plan in a de-identified format for commercial purposes, including research and analytic purposes.

For complete listings of your medical records or billing statements Vermilion Parish School Board recommends that you contact your health care provider. Providers may charge you reasonable fees to cover their costs for providing records or completing requested forms.

If you request medical forms or records from UnitedHealthcare, they also may charge you reasonable fees to cover costs for completing the forms or providing the records.

In some cases, Vermilion Parish School Board and UnitedHealthcare will designate other persons or entities to request records or information from or related to you, and to release those records as necessary. UnitedHealthcare's designees have the same rights to this information as does the Plan Administrator.

Incentives to Providers

Network providers may be provided financial incentives by UnitedHealthcare to promote the delivery of health care in a cost efficient and effective manner. These financial incentives are not intended to affect your access to health care.

Examples of financial incentives for Network providers are:

      bonuses for performance based on factors that may include quality, member satisfaction, and/or cost-effectiveness; or

      a practice called capitation which is when a group of Network providers receives a monthly payment from UnitedHealthcare for each Covered Person who selects a Network provider within the group to perform or coordinate certain health services. The Network providers receive this monthly payment regardless of whether the cost of providing or arranging to provide the Covered Person's health care is less than or more than the payment.

If you have any questions regarding financial incentives you may contact the telephone number on your ID card. You can ask whether your Network provider is paid by any financial incentive, including those listed above; however, the specific terms of the contract, including rates of payment, are confidential and cannot be disclosed. In addition, you may choose to discuss these financial incentives with your Network provider.

Incentives to You

Sometimes you may be offered coupons or other incentives to encourage you to participate in various wellness programs or certain disease management programs. The decision about whether or not to participate is yours alone but Vermilion Parish School Board recommends that you discuss participating in such programs with your Physician. These incentives are not Benefits and do not alter or affect your Benefits. You may call the number on the back of your ID card if you have any questions.

Rebates and Other Payments

Vermilion Parish School Board and UnitedHealthcare may receive rebates for certain drugs that are administered to you in a Physician's office, or at a Hospital or Alternate Facility. This includes rebates for those drugs that are administered to you before you meet your Annual Deductible. Vermilion Parish School Board and UnitedHealthcare do not pass these rebates on to you, nor are they applied to your Annual Deductible or taken into account in determining your Copays or Coinsurance.

Workers' Compensation Not Affected

Benefits provided under the Plan do not substitute for and do not affect any requirements for coverage by workers' compensation insurance.

Future of the Plan

Although the Company expects to continue the Plan indefinitely, it reserves the right to discontinue, alter or modify the Plan in whole or in part, at any time and for any reason, at its sole determination.

The Company's decision to terminate or amend a Plan may be due to changes in federal or state laws governing employee benefits, the requirements of the Internal Revenue Code or Employee Retirement Income Security Act of 1974 (ERISA), or any other reason. A plan change may transfer plan assets and debts to another plan or split a plan into two or more parts. If the Company does change or terminate a plan, it may decide to set up a different plan providing similar or different benefits.

If this Plan is terminated, Covered Persons will not have the right to any other Benefits from the Plan, other than for those claims incurred prior to the date of termination, or as otherwise provided under the Plan. In addition, if the Plan is amended, Covered Persons may be subject to altered coverage and Benefits.

The amount and form of any final benefit you receive will depend on any Plan document or contract provisions affecting the Plan and Company decisions. After all Benefits have been paid and other requirements of the law have been met, certain remaining Plan assets will be turned over to the Company and others as may be required by any applicable law.

Plan Document

This Summary Plan Description (SPD) represents an overview of your Benefits. In the event there is a discrepancy between the SPD and the official plan document, the plan document will govern. A copy of the plan document is available for your inspection during regular business hours in the office of the Plan Administrator. You (or your personal representative) may obtain a copy of this document by written request to the Plan Administrator, for a nominal charge.

 


SECTION 14 - GLOSSARY

What this section includes:

      Definitions of terms used throughout this SPD.

Many of the terms used throughout this SPD may be unfamiliar to you or have a specific meaning with regard to the way the Plan is administered and how Benefits are paid. This section defines terms used throughout this SPD, but it does not describe the Benefits provided by the Plan.

Addendum any attached written description of additional or revised provisions to the Plan. The benefits and exclusions of this SPD and any amendments thereto shall apply to the Addendum except that in the case of any conflict between the Addendum and SPD and/or Amendments to the SPD, the Addendum shall be controlling.

Alternate Facility – a health care facility that is not a Hospital and that provides one or more of the following services on an outpatient basis, as permitted by law:

      surgical services;

      Emergency Health Services; or

      rehabilitative, laboratory, diagnostic or therapeutic services.

An Alternate Facility may also provide Mental Health or Substance Use Disorder Services on an outpatient basis or inpatient basis (for example a Residential Treatment Facility).

Amendment – any attached written description of additional or alternative provisions to the Plan. Amendments are effective only when distributed by the Plan Sponsor or the Plan Administrator. Amendments are subject to all conditions, limitations and exclusions of the Plan, except for those that the amendment is specifically changing.

Annual Deductible (or Deductible) – the amount you must pay for Covered Health Services in a calendar year before the Plan will begin paying Benefits in that calendar year. The Deductible is shown in the first table in Section 5, Plan Highlights.‍‍‍‍‍‍‍

Autism Spectrum Disorders a group of neurobiological disorders that includes Autistic Disorder, Rhett's Syndrome, Asperger's Disorder, Childhood Disintegrated Disorder, and Pervasive Development Disorders Not Otherwise Specified (PDDNOS).

Benefits – Plan payments for Covered Health Services, subject to the terms and conditions of the Plan and any Addendums and/or Amendments.

Cancer Resource Services (CRS) – a program administered by UnitedHealthcare or its affiliates made available to you by Vermilion Parish School Board. The CRS program provides:

      specialized consulting services, on a limited basis, to Employees and enrolled Dependents with cancer;

      access to cancer centers with expertise in treating the most rare or complex cancers; and

      education to help patients understand their cancer and make informed decisions about their care and course of treatment.

Claims Administrator – UnitedHealthcare (also known as United HealthCare Services, Inc.) and its affiliates, who provide certain claim administration services for the Plan.

Clinical Trial – a scientific study designed to identify new health services that improve health outcomes. In a Clinical Trial, two or more treatments are compared to each other and the patient is not allowed to choose which treatment will be received.

COBRA – see Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

Coinsurance – the percentage of Eligible Expenses you are required to pay for certain Covered Health Services as described in Section 3, How the Plan Works.

Company – Vermilion Parish School Board.

Congenital Anomaly – a physical developmental defect that is present at birth and is identified within the first twelve months of birth.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) – a federal law that requires employers to offer continued health insurance coverage to certain employees and their dependents whose group health insurance has been terminated.

Continuous Creditable Coverage – health care coverage under any of the types of plans listed below, during which there was no break in coverage of 63 consecutive days or more:

      a group health plan;

      health insurance coverage;

      Medicare;

      Medicaid;

      medical and dental care for members and certain former members of the uniformed services, and for their dependents;

      a medical care program of the Indian Health Services Program or a tribal organization;

      a state health benefits risk pool;

      The Federal Employees Health Benefits Program;

      The State Children's Health Insurance Program (S-CHIP);

      health plans established and maintained by foreign governments or political subdivisions and by the U.S. government;

      any public health benefit program provided by a state, county, or other political subdivision of a state; or

      a health benefit plan under the Peace Corps Act.

If you or your eligible Dependents were covered by any of the above plans before first becoming covered by this Plan, you should have received a Certificate of Creditable Coverage when that plan's coverage ended.

A waiting period for health care coverage will be included in the period of time counted as Continuous Creditable Coverage.

Copayment (or Copay) – the set dollar amount you are required to pay for certain Covered Health Services as described in Section 3, How the Plan Works.

Cosmetic Procedures – procedures or services that change or improve appearance without significantly improving physiological function, as determined by the Claims Administrator. Reshaping a nose with a prominent bump is a good example of a Cosmetic Procedure because appearance would be improved, but there would be no improvement in function like breathing.

Cost-Effective – the least expensive equipment that performs the necessary function. This term applies to Durable Medical Equipment and prosthetic devices.

Covered Health Services – those health services, including services or supplies, which UnitedHealthcare determines to be:

      provided for the purpose of preventing, diagnosing or treating Sickness, Injury, Mental Illness, Substance Use Disorders, or their symptoms;

      included in Sections 5 and 6, Plan Highlights and Additional Coverage Details;

      provided to a Covered Person who meets the Plan's eligibility requirements, as described under Eligibility in Section 2, Introduction; and

      not identified in Section 8, Exclusions.

The Claims Administrator maintains clinical protocols that describe the scientific evidence, prevailing medical standards and clinical guidelines supporting its determinations regarding specific services. You can access these clinical protocols (as revised from time to time) on www.myuhc.com or by calling the number on the back of your ID card.

This information is available to Physicians and other health care professionals on UnitedHealthcareOnline.

Covered Person – either the Employee or an enrolled Dependent only while enrolled and eligible for Benefits under the Plan. References to "you" and "your" throughout this SPD are references to a Covered Person.

CRS – see Cancer Resource Services (CRS).

Custodial Care – services that do not require special skills or training and that:

      provide assistance in activities of daily living (including but not limited to feeding, dressing, bathing, ostomy care, incontinence care, checking of routine vital signs, transferring and ambulating);

      are provided for the primary purpose of meeting the personal needs of the patient or maintaining a level of function (even if the specific services are considered to be skilled services), as opposed to improving that function to an extent that might allow for a more independent existence; or

      do not require continued administration by trained medical personnel in order to be delivered safely and effectively.

Deductible see Annual Deductible.

Dependent – an individual who meets the eligibility requirements specified in the Plan, as described under Eligibility in Section 2, Introduction. A Dependent does not include anyone who is also enrolled as ‍an Employee.‍ No one can be a Dependent of more than one ‍Employee.

Designated Facility – a facility that has entered into an agreement with the Claims Administrator or with an organization contracting on behalf of the Plan, to provide Covered Health Services for the treatment of specified diseases or conditions. A Designated Facility may or may not be located within your geographic area.

To be considered a Designated Facility, a facility must meet certain standards of excellence and have a proven track record of treating specified conditions.

DME – see Durable Medical Equipment (DME).

Durable Medical Equipment (DME) – medical equipment that is all of the following:

      used to serve a medical purpose with respect to treatment of a Sickness, Injury or their symptoms;

      not disposable;

      not of use to a person in the absence of a Sickness, Injury or their symptoms;

      durable enough to withstand repeated use;

      not implantable within the body; and

      appropriate for use, and primarily used, within the home.

Eligible Expenses – charges for Covered Health Services that are provided while the Plan is in effect, determined as follows:

 

 

For Services Provided by a:

Eligible Expenses are Based On:

Network Provider

Contracted rates with the provider

Non-Network Provider

      negotiated rates agreed to by the non-Network provider and either the Claims Administrator or one of its vendors, affiliates or subcontractors, at the discretion of the Claims Administrator.

      if rates have not been negotiated, then one of the following amounts:

-        140 percent of the published rates allowed by the Centers for Medicare and Medicaid Services (CMS) for Medicare for the same or similar service within the geographic market, or

-        When a rate is not published by CMS for the service, the Claims Administrator uses an available gap methodology to determine a rate for the service as follows –

·       For services other than Pharmaceutical Products, the Claims Administrator uses a gap methodology that uses a relative value scale, which is usually based on the difficulty, time, work, risk and resources of the service. The relative value scale currently used is created by Ingenix, Inc. If the Ingenix, Inc. relative value scale becomes no longer available, a comparable scale will be used. The Claims Administrator and Ingenix, Inc. are related companies through common ownership by UnitedHealth Group.

·       For Pharmaceutical Products, the Claims Administrator uses gap methodologies that are similar to the pricing methodology used by CMS, and produces fees based on published acquisition costs or average wholesale price for the pharmaceuticals. These methodologies are currently created by RJ Health Systems, Thomson Reuters (published in its Red Book), or the Claims Administrator based on an internally developed pharmaceutical pricing resource.

-        When a rate is not published by CMS for the service and a gap methodology does not apply to the service, or the provider does not submit sufficient information on the claim to pay it under CMS published rates or a gap methodology, the Eligible Expense is based on 50 percent of the provider’s billed charge, except that certain Eligible Expenses for mental health and substance use disorder services are based on 80 percent of the billed charge.

 

The Claims Administrator updates the CMS published rate data on a regular basis when updated data from CMS becomes available. Theses updates are typically implemented within 30 to 90 days after CMS updates its data.

These provisions do not apply if you receive Covered Health Services from a non-Network provider in an Emergency or as otherwise arranged by the Claims Administrator. In that case, Eligible Expenses are the amounts billed by the provider, unless the Claims Administrator negotiates lower rates.


For certain Covered Health Services, you are required to pay a percentage of Eligible Expenses in the form of a Copay and/or Coinsurance.

Eligible Expenses are subject to the Claims Administrator's reimbursement policy guidelines. You may request a copy of the guidelines related to your claim from the Claims Administrator.

Emergency – a serious medical condition or symptom resulting from Injury, Sickness or Mental Illness, or substance use disorders which:

      arises suddenly; and

      in the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health.

Emergency Health Services – health care services and supplies necessary for the treatment of an Emergency.

Employee – a full-time Employee of the Employer who meets the eligibility requirements specified in the Plan, as described under Eligibility in Section 2, Introduction. An Employee must live and/or work in the United States.

Employee Retirement Income Security Act of 1974 (ERISA) – the federal legislation that regulates retirement and employee welfare benefit programs maintained by employers and unions.

Employer – Vermilion Parish School Board.

EOB – see Explanation of Benefits (EOB).

ERISA – see Employee Retirement Income Security Act of 1974 (ERISA).

Experimental or Investigational Services – medical, surgical, diagnostic, psychiatric, mental health, substance use disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time UnitedHealthcare‍ and Vermilion Parish School Board make a determination regarding coverage in a particular case, are determined to be any of the following:

      not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use;

      subject to review and approval by any institutional review board for the proposed use (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be Experimental or Investigational); or

      the subject of an ongoing Clinical Trial that meets the definition of a Phase 1, 2 or 3 Clinical Trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

Exceptions:

      If you have a life-threatening Sickness or condition (one that is likely to cause death within one year of the request for treatment), UnitedHealthcare and Vermilion Parish School Board may, at their discretion, consider an otherwise Experimental or Investigational Service to be a Covered Health Service for that Sickness or condition. Prior to such consideration, UnitedHealthcare and Vermilion Parish School Board must determine that, although unproven, the service has significant potential as an effective treatment for that Sickness or condition.

Explanation of Benefits (EOB) – a statement provided by UnitedHealthcare to you, your Physician, or another health care professional that explains:

      the Benefits provided (if any);

      the allowable reimbursement amounts;

      Deductibles;

      Coinsurance;

      any other reductions taken;

      the net amount paid by the Plan; and

      the reason(s) why the service or supply was not covered by the Plan.

Health Statement(s) – a single, integrated statement that summarizes EOB information by providing detailed content on account balances and claim activity.

Home Health Agency – a program or organization authorized by law to provide health care services in the home.

Hospital – an institution, operated as required by law, which is:

      primarily engaged in providing health services, on an inpatient basis, for the acute care and treatment of sick or injured individuals. Care is provided through medical, mental health, substance use disorders, diagnostic and surgical facilities, by or under the supervision of a staff of Physicians; and

      has 24 hour nursing services.

A Hospital is not primarily a place for rest, Custodial Care or care of the aged and is not a Skilled Nursing Facility, convalescent home or similar institution.

Injury – bodily damage other than Sickness, including all related conditions and recurrent symptoms.

Inpatient Rehabilitation Facility – a long term acute rehabilitation center, a Hospital (or a special unit of a Hospital designated as an Inpatient Rehabilitation Facility) that provides rehabilitation services (including physical therapy, occupational therapy and/or speech therapy) on an inpatient basis, as authorized by law.

Inpatient Stay – an uninterrupted confinement, following formal admission to a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility.

Intensive Outpatient Treatment – a structured outpatient Mental Health or Substance Use Disorder treatment program that may be free-standing or Hospital-based and provides services for at least three hours per day, two or more days per week.

Intermittent Care – skilled nursing care that is provided or needed either:

      fewer than seven days each week; or

      fewer than eight hours each day for periods of 21 days or less.

Exceptions may be made in special circumstances when the need for additional care is finite and predictable.

Medicaid – a federal program administered and operated individually by participating state and territorial governments that provides medical benefits to eligible low-income people needing health care. The federal and state governments share the program's costs.

Medicare – Parts A, B, C and D of the insurance program established by Title XVIII, United States Social Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended.

Mental Health Services – Covered Health Services for the diagnosis and treatment of Mental Illnesses. The fact that a condition is listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment for the condition is a Covered Health Service.

Mental Health/Substance Use Disorder (MH/SUD) Administrator – the organization or individual designated by Vermilion Parish School Board who provides or arranges Mental Health and Substance Use Disorder Services under the Plan.

Mental Illness – mental health or psychiatric diagnostic categories listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless they are listed in Section 8, Exclusions.

Network – when used to describe a provider of health care services, this means a provider that has a participation agreement in effect (either directly or indirectly) with the Claims Administrator or with its affiliate to participate in the Network; however, this does not include those providers who have agreed to discount their charges for Covered Health Services by way of their participation in the Shared Savings Program. The Claims Administrator's affiliates are those entities affiliated with the Claims Administrator through common ownership or control with the Claims Administrator or with the Claims Administrator's ultimate corporate parent, including direct and indirect subsidiaries.

A provider may enter into an agreement to provide only certain Covered Health Services, but not all Covered Health Services, or to be a Network provider for only some products. In this case, the provider will be a Network provider for the Covered Health Services and products included in the participation agreement, and a non-Network provider for other Covered Health Services and products. The participation status of providers will change from time to time.

Network Benefits - description of how Benefits are paid for Covered Health Services provided by Network providers. Refer to Section 5, Plan Highlights for details about how Network Benefits apply.

Non-Network Benefits - description of how Benefits are paid for Covered Health Services provided by non-Network providers. Refer to Section 5, Plan Highlights for details about how Non-Network Benefits apply.

Open Enrollment – the period of time, determined by Vermilion Parish School Board, during which eligible Employees may enroll themselves and their Dependents under the Plan. Vermilion Parish School Board determines the period of time that is the Open Enrollment period.

Out-of-Pocket Maximum – the maximum amount you pay every calendar year. Refer to Section 5, Plan Highlights for the Out-of-Pocket Maximum amount. See Section 3, How the Plan Works for a description of how the Out-of-Pocket Maximum works.‍

Partial Hospitalization/Day Treatment – a structured ambulatory program that may be a free-standing or Hospital-based program and that provides services for at least 20 hours per week.

Personal Health Support – programs provided by the Claims Administrator that focus on prevention, education, and closing the gaps in care designed to encourage an efficient system of care for you and your covered Dependents.

Personal Health Support Nurse – the primary nurse that UnitedHealthcare may assign to you if you have a chronic or complex health condition. If a Personal Health Support Nurse is assigned to you, this nurse will call you to assess your progress and provide you with information and education.

Physician – any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by law.

Please note: Any podiatrist, dentist, psychologist, chiropractor, optometrist‍ or other provider who acts within the scope of his or her license will be considered on the same basis as a Physician. The fact that a provider is described as a Physician does not mean that Benefits for services from that provider are available to you under the Plan.

Plan – The Vermilion Parish School Board Medical Plan.

Plan Administrator – Vermilion Parish School Board or its designee.

Plan Sponsor – Vermilion Parish School Board.

Preexisting Condition – any Sickness or Injury that is identified by the Plan Administrator as having been diagnosed or treated, or for which Prescription Drugs were prescribed or taken within the six months before coverage under this Plan begins (or the first day of any waiting period, if earlier). A Preexisting Condition does not include Pregnancy. Genetic information is not an indicator of a Preexisting Condition, if there is not a diagnosis of a condition related to the genetic information.

If you have Continuous Creditable Coverage, you or your Dependent will be eligible to receive Plan Benefits for a Preexisting Condition. Continuous Creditable Coverage is defined in this section.

Pregnancy – includes prenatal care, postnatal care, childbirth, and any complications associated with the above.

Private Duty Nursing – nursing care that is provided to a patient on a one-to-one basis by licensed nurses in an inpatient or a home setting when any of the following are true:

      no skilled services are identified;

      skilled nursing resources are available in the facility;

      the skilled care can be provided by a Home Health Agency on a per visit basis for a specific purpose; or

      the service is provided to a Covered Person by an independent nurse who is hired directly by the Covered Person or his/her family. This includes nursing services provided on an inpatient or a home-care basis, whether the service is skilled or non-skilled independent nursing.

Reconstructive Procedure – a procedure performed to address a physical impairment where the expected outcome is restored or improved function. The primary purpose of a Reconstructive Procedure is either to treat a medical condition or to improve or restore physiologic function. Reconstructive Procedures include surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not changed or improved physical appearance. The fact that a person may suffer psychologically as a result of the impairment does not classify surgery or any other procedure done to relieve the impairment as a Reconstructive Procedure.

Residential Treatment Facility – a facility which provides a program of effective Mental Health Services or Substance Use Disorder Services treatment and which meets all of the following requirements:

      it is established and operated in accordance with applicable state law for residential treatment programs;

      it provides a program of treatment under the active participation and direction of a Physician and approved by the Mental Health/Substance Use Disorder Administrator;

      it has or maintains a written, specific and detailed treatment program requiring full-time residence and full-time participation by the patient; and

      it provides at least the following basic services in a 24-hour per day, structured milieu:

-        room and board;

-        evaluation and diagnosis;

-        counseling; and

-        referral and orientation to specialized community resources.

A Residential Treatment Facility that qualifies as a Hospital is considered a Hospital.

Retired Employee – an Employee who retires while covered under the Plan.

Semi-private Room - a room with two or more beds. When an Inpatient Stay in a Semi-private Room is a Covered Health Service, the difference in cost between a Semi-private Room and a private room is a benefit only when a private room is necessary in terms of generally accepted medical practice, or when a Semi-private Room is not available.

Shared Savings Program - the Shared Savings Program provides access to discounts from non-Network Physicians who participate in that program. UnitedHealthcare will use the Shared Savings Program to pay claims when doing so will lower Eligible Expenses. While UnitedHealthcare might negotiate lower Eligible Expenses for Non-Network Benefits, the Coinsurance will stay the same as described in Section 5, Plan Highlights.

UnitedHealthcare does not credential the Shared Savings Program providers and the Shared Savings Program providers are not Network providers. Accordingly, in benefit plans that have both Network and non-Network levels of Benefits, Benefits for Covered Health Services provided by Shared Savings Program providers will be paid at the non-Network Benefit level (except in situations when Benefits for Covered Health Services provided by non-Network providers are payable at Network Benefit levels, as in the case of Emergency Health Services). When UnitedHealthcare uses the Shared Savings Program to pay a claim, the patient responsibility is limited to Coinsurance calculated on the contracted rate paid to the provider, in addition to any required Annual Deductible.

Sickness – physical illness, disease or Pregnancy. The term Sickness as used in this SPD does not include Mental Illness or substance use disorder, regardless of the cause or origin of the Mental Illness or substance use disorder.

Skilled Care – skilled nursing, teaching, and rehabilitation services when:

      they are delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome and provide for the safety of the patient;

      a Physician orders them;

      they are not delivered for the purpose of assisting with activities of daily living, including dressing, feeding, bathing or transferring from a bed to a chair;

      they require clinical training in order to be delivered safely and effectively; and

      they are not Custodial Care, as defined in this section.

Skilled Nursing Facility – a nursing facility that is licensed and operated as required by law. A Skilled Nursing Facility that is part of a Hospital is considered a Skilled Nursing Facility for purposes of the Plan.

Spouse – an individual to whom you are legally married‍.

Substance Use Disorder Services - Covered Health Services for the diagnosis and treatment of alcoholism and substance use disorders that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded.

Total Disability – an Employee's inability to perform all substantial job duties because of physical or mental impairment, or a Dependent's or retired person's inability to perform the normal activities of a person of like age and gender.

Transitional Care – Mental Health Services/Substance Use Disorder Services that are provided through transitional living facilities, group homes and supervised apartments that provide 24-hour supervision that are either:

      sober living arrangements such as drug-free housing, alcohol/drug halfway houses. These are transitional, supervised living arrangements that provide stable and safe housing, an alcohol/drug-free environment and support for recovery. A sober living arrangement may be utilized as an adjunct to ambulatory treatment when treatment doesn't offer the intensity and structure needed to assist the Covered Person with recovery; or

      supervised living arrangement which are residences such as transitional living facilities, group homes and supervised apartments that provide members with stable and safe housing and the opportunity to learn how to manage their activities of daily living. Supervised living arrangements may be utilized as an adjunct to treatment when treatment doesn't offer the intensity and structure needed to assist the Covered Person with recovery.

UnitedHealth Premium ProgramSM – a program that identifies Network Physicians or facilities that have been designated as a UnitedHealth Premium ProgramSM Physician or facility for certain medical conditions.

To be designated as a UnitedHealth PremiumSM provider, Physicians and facilities must meet program criteria. The fact that a Physician or facility is a Network Physician or facility does not mean that it is a UnitedHealth Premium ProgramSM Physician or facility.

Unproven Services – health services, including medications that are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature:

      Well-conducted randomized controlled trials are two or more treatments compared to each other, with the patient not being allowed to choose which treatment is received.

      Well-conducted cohort studies from more than one institution are studies in which patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group.

UnitedHealthcare has a process by which it compiles and reviews clinical evidence with respect to certain health services. From time to time, UnitedHealthcare issues medical and drug policies that describe the clinical evidence available with respect to specific health care services. These medical and drug policies are subject to change without prior notice. You can view these policies at www.myuhc.com.

Please note:

      If you have a life threatening Sickness or condition (one that is likely to cause death within one year of the request for treatment), UnitedHealthcare and Vermilion Parish School Board may, at their discretion, consider an otherwise Unproven Service to be a Covered Health Service for that Sickness or condition. Prior to such a consideration, UnitedHealthcare and Vermilion Parish School Board must first establish that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that Sickness or condition.

The decision about whether such a service can be deemed a Covered Health Service is solely at UnitedHealthcare and Vermilion Parish School Board's discretion. Other apparently similar promising but unproven services may not qualify.

Urgent Care – treatment of an unexpected Sickness or Injury that is not life-threatening but requires outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering, such as high fever, a skin rash, or an ear infection.

Urgent Care Center – a facility that provides Urgent Care services, as previously defined in this section. In general, Urgent Care Centers:

      do not require an appointment;

      are open outside of normal business hours, so you can get medical attention for minor illnesses that occur at night or on weekends; and

      provide an alternative if you need immediate medical attention, but your Physician cannot see you right away.


SECTION 15 - PRESCRIPTION DRUGS

What this section includes:

      Benefits available for Prescription Drugs;

      How to utilize the retail and mail order service for obtaining Prescription Drugs;

      Any benefit limitations and exclusions that exist for Prescription Drugs; and

      Definitions of terms used throughout this section related to the Prescription Drug Plan.

Prescription Drug Coverage Highlights

The table below provides an overview of the Plan's Prescription Drug coverage. It includes Copay amounts that apply when you have a prescription filled at a ‍‍Pharmacy‍. For detailed descriptions of your Benefits, refer to Retail and Mail Order in this section.

Covered Health Services1,3

Percentage of Prescription Drug Charge Payable by the Plan:

Percentage of Predominant Reimbursement Rate Payable by the Plan:

Network

Non-Network

Retail - up to a 31-day supply[2]

100% after you ‍pay a:

      tier-1

$10 Copay

$10 Copay

      tier-2

$35 Copay

$35 Copay

      tier-3

$75 Copay

$75 Copay

Mail order - up to a 90-day supply[2,3]

100% after you ‍pay a:

      tier-1

$25 Copay

      tier-2

$87.50 Copay

      tier-3

$187.50 Copay

1You, your Physician or your pharmacist must notify UnitedHealthcare to receive full Benefits for certain Prescription Drugs. Otherwise, you may pay more out-of-pocket. See Notification Requirements in this section for details.

2The Plan pays Benefits for Specialty Prescription Drugs as described in this table.

3You are not responsible for paying a Copayment and/or Coinsurance for Preventive Care Medications.

Note: The Coordination of Benefits provision described in Section 10, Coordination of Benefits (COB) does not apply to covered Prescription Drugs as described in this section. Prescription Drug Benefits will not be coordinated with those of any other health coverage plan.

Identification Card (ID Card) – Network Pharmacy

You must either show your ID card at the time you obtain your Prescription Drug at a Network Pharmacy or you must provide the Network Pharmacy with identifying information that can be verified by the Claims Administrator during regular business hours.

If you don't show your ID card or provide verifiable information at a Network Pharmacy, you will be required to pay the Usual and Customary Charge for the Prescription Drug at the pharmacy.

Benefit Levels

Benefits are available for outpatient Prescription Drugs that are considered Covered Health Services.

The Plan pays Benefits at different levels for tier-1, tier-2 and tier-3‍ Prescription Drugs. All Prescription Drugs covered by the Plan are categorized into these three ‍tiers on the Prescription Drug List (PDL). The tier status of a Prescription Drug can change periodically, generally quarterly but no more than six times per calendar year, based on the Prescription Drug List Management Committee's periodic tiering decisions. When that occurs, you may pay more or less for a Prescription Drug, depending on its tier assignment. Since the PDL may change periodically, you can visit www.myuhc.com or call UnitedHealthcare at the toll-free ‍‍number on your ID card for the most current information.

Each tier is assigned a Copay, which is the amount you pay‍ when you visit the pharmacy or order your medications through mail order. Your Copay will also depend on whether or not you visit the pharmacy or use the mail order service - see the table shown at the beginning of this section for further details. Here's how the tier system works:

      Tier-1 is your lowest Copay option. For the lowest out-of-pocket expense, you should consider tier-1 drugs if you and your Physician decide they are appropriate for your treatment.

      Tier-2 is your middle Copay option. Consider a tier-2 drug if no tier-1 drug is available to treat your condition.

      Tier-3 is your highest Copay option. The drugs in tier-3 are usually more costly. Sometimes there are alternatives available in tier-1 or tier-2.

For Prescription Drugs at a retail Network Pharmacy, you are responsible for paying the lower of:

      the applicable Copay;

      the Network Pharmacy's Usual and Customary Charge for the Prescription Drug; or

      the Prescription Drug Charge that UnitedHealthcare agreed to pay the Network Pharmacy.

For Prescription Drugs from a mail order Network Pharmacy, you are responsible for paying the lower of:

      the applicable Copay; or

      the Prescription Drug Charge for that particular Prescription Drug.

Retail

The Plan has a Network of participating retail pharmacies, which includes many large drug store chains. You can obtain information about Network Pharmacies by contacting UnitedHealthcare at the toll-free ‍‍number on your ID card or by logging onto www.myuhc.com.

To obtain your prescription from a retail pharmacy, simply present your ID card and pay the Copay‍. The Plan pays Benefits for certain covered Prescription Drugs:

      as written by a Physician;

      up to a consecutive 31-day supply, unless adjusted based on the drug manufacturer's packaging size or based on supply limits;

      when a Prescription Drug is packaged or designed to deliver in a manner that provides more than a consecutive 31-day supply, the Copay that applies will reflect the number of days dispensed; and

      a one-cycle supply of an oral contraceptive. You may obtain up to three cycles at one time if you pay a Copay for each cycle supplied.

Note:Pharmacy Benefits apply only if your prescription is for a Covered Health Service, and not for Experimental or Investigational, or Unproven Services. Otherwise, you are responsible for paying 100% of the cost.

Mail Order

The mail order service may allow you to purchase up to a 90-day supply of a covered maintenance drug through the mail. Maintenance drugs help in the treatment of chronic illnesses, such as heart conditions, allergies, high blood pressure, and arthritis.

To use the mail order service, all you need to do is complete a patient profile and enclose your prescription order or refill. Your medication, plus instructions for obtaining refills, will arrive by mail about 14 days after your order is received. If you need a patient profile form, or if you have any questions, you can reach UnitedHealthcare at the toll-free ‍‍number on your ID card.

The Plan pays mail order Benefits for certain covered Prescription Drugs:

      as written by a Physician; and

      up to a consecutive 90-day supply, unless adjusted based on the drug manufacturer's packaging size or based on supply limits.

You may be required to fill an initial Prescription Drug order and obtain one refill through a retail pharmacy prior to using a mail order Network Pharmacy.

Note:  To maximize your benefit, ask your Physician to write your prescription order or refill for a 90-day supply, with refills when appropriate. You will be charged a mail order Copay for any prescription order or refill if you use the mail order service, regardless of the number of days' supply that is written on the order or refill. Be sure your Physician writes your mail order or refill for a 90-day supply, not a 30-day supply with three refills.

Benefits for Preventive Care Medications

Benefits under the Prescription Drug Plan include those for Preventive Care Medications as defined under Glossary – Prescription Drugs. You may determine whether a drug is a Preventive Care Medication through the internet at www.myuhc.com or by calling UnitedHealthcare at the toll-free telephone number on your ID card.

Designated Pharmacy

If you require certain Prescription Drugs, UnitedHealthcare may direct you to a Designated Pharmacy with whom it has an arrangement to provide those Prescription Drugs.

Specialty Prescription Drugs

You may fill a prescription for Specialty Prescription Drugs up to two times at any ‍Pharmacy. However, after that you will be directed to a Designated Pharmacy and if you choose not to obtain your Specialty Prescription Drugs from a Designated Pharmacy, no Benefits will be paid and you will be responsible for paying all charges.

Please see the Prescription Drug Glossary in this section for definitions of Specialty Prescription Drug and Designated Pharmacy.

Select Designated Pharmacy

You may fill a prescription for a Select Prescription Drug up to two times at any retail ‍Pharmacy. However, after that you will be directed to a Designated Pharmacy. If you are directed to a Designated Pharmacy and you choose not to obtain your Prescription Drug from a Designated Pharmacy, non-Network Benefits will apply for that Select Prescription Drug.

For more information, visit myuhc.com or call UnitedHealthcare at the toll-free number on your ID card.

Please see the Prescription Drug Glossary in this section for the definition of Select Prescription Drug.

Want to lower your out-of-pocket Prescription Drug costs?

Consider tier-1 Prescription Drugs, if you and your Physician decide they are appropriate.

Assigning Prescription Drugs to the PDL

UnitedHealthcare's Prescription Drug List (PDL) Management Committee makes the final approval of Prescription Drug placement in tiers. In its evaluation of each Prescription Drug, the PDL Management Committee takes into account a number of factors including, but not limited to, clinical and economic factors. Clinical factors may include:

      evaluations of the place in therapy;

      relative safety and efficacy; and

      whether supply limits or notification requirements should apply.

Economic factors may include:

      the acquisition cost of the Prescription Drug; and

      available rebates and assessments on the cost effectiveness of the Prescription Drug.

Some Prescription Drugs are most cost effective for specific indications as compared to others, therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed.

When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician.

The PDL Management Committee may periodically change the placement of a Prescription Drug among the tiers. These changes will not occur more than six times per calendar year and may occur without prior notice to you.

Prescription Drug, Prescription Drug List (PDL), and Prescription Drug List (PDL) Management Committee are defined at the end of this section.

Prescription Drug List (PDL)

The Prescription Drug List (PDL) is a tool that helps guide you and your Physician in choosing the medications that allow the most effective and affordable use of your Prescription Drug benefit.

Notification Requirements

Before certain Prescription Drugs are dispensed to you, it is the responsibility of your Physician, your pharmacist or you to notify UnitedHealthcare. UnitedHealthcare will determine if the Prescription Drug, in accordance with UnitedHealthcare approved guidelines, is both:

      a Covered Health Service as defined by the Plan; and

      not Experimental or Investigational or Unproven, as defined in Section 14, Glossary.

The Plan may also require you to notify UnitedHealthcare so UnitedHealthcare can determine whether the Prescription Drug Product, in accordance with its approved guidelines, was prescribed by a Specialist Physician.

Network Pharmacy Notification

When Prescription Drugs are dispensed at a Network Pharmacy, the prescribing provider, the pharmacist, or you are responsible for notifying the Claims Administrator.

Non-Network Pharmacy Notification

When Prescription Drugs are dispensed at a non-Network Pharmacy, you or your Physician are responsible for notifying the Claims Administrator as required.

If UnitedHealthcare is not notified before the Prescription Drug is dispensed, you may pay more for that Prescription Drug order or refill. You will be required to pay for the Prescription Drug at the time of purchase. The contracted pharmacy reimbursement rates (the Prescription Drug Charge) will not be available to you at a non-Network Pharmacy. If UnitedHealthcare is not notified before you purchase the Prescription Drug, you can request reimbursement after you receive the Prescription Drug - see Section 9, Claims Procedures, for information on how to file a claim.

When you submit a claim on this basis, you may pay more because you did not notify the Claims Administrator before the Prescription Drug was dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge (for Prescription Drugs from a Network Pharmacy) or the Predominant Reimbursement Rate (for Prescription Drugs from a non-Network Pharmacy), less the required Copayment and/or Coinsurance‍, Therapeutic Class Charge and any Deductible that applies.

To determine if a Prescription Drug requires notification, either visit www.myuhc.com or call the toll-free ‍‍number on your ID card. The Prescription Drugs requiring notification are subject to UnitedHealthcare's periodic review and modification.

Benefits may not be available for the Prescription Drug after the Claims Administrator reviews the documentation provided and determines that the Prescription Drug is not a Covered Health Service or it is an Experimental or Investigational or Unproven Service.

UnitedHealthcare may also require notification for certain programs which may have specific requirements for participation and/or activation of an enhanced level of Benefits associated with such programs. You may access information on available programs and any applicable notification, participation or activation requirements associated with such programs through the Internet at www.myuhc.com or by calling the toll-free number on your ID card.

Prescription Drug Benefit Claims

For Prescription Drug claims procedures, please refer to Section 9, Claims Procedures.

Limitation on Selection of Pharmacies

If the Claims Administrator determines that you may be using Prescription Drugs in a harmful or abusive manner, or with harmful frequency, your selection of Network Pharmacies may be limited. If this happens, you may be required to select a single Network Pharmacy that will provide and coordinate all future pharmacy services. Benefits will be paid only if you use the designated single Network Pharmacy. If you don't make a selection within 31 days of the date the Plan Administrator notifies you, the Claims Administrator will select a single Network Pharmacy for you.

Supply Limits

Some Prescription Drugs are subject to supply limits that may restrict the amount dispensed per prescription order or refill. To determine if a Prescription Drug has been assigned a maximum quantity level for dispensing, either visit www.myuhc.com or call the toll-free ‍‍number on your ID card. Whether or not a Prescription Drug has a supply limit is subject to UnitedHealthcare's periodic review and modification.

Note: Some products are subject to additional supply limits based on criteria that the Plan Administrator and the Claims Administrator have developed, subject to periodic review and modification. The limit may restrict the amount dispensed per prescription order or refill and/or the amount dispensed per month's supply.

If a Brand-name Drug Becomes Available as a Generic

If a Brand-name Prescription Drug becomes available as a Generic drug, the tier placement of the Brand-name Drug may change‍. As a result, your Copay may change. You will pay the Copay applicable for the tier to which the Prescription Drug is assigned.

Special Programs

Vermilion Parish School Board and UnitedHealthcare may have certain programs in which you may receive an enhanced or reduced benefit based on your actions such as adherence/compliance to medication or treatment regimens and/or participation in health management programs. You may access information on these programs through the Internet at www.myuhc.com or by calling the ‍‍number on the back of your ID card.

Prescription Drug Products Prescribed by a Specialist Physician

You may receive an enhanced or reduced benefit, or no benefit, based on whether the Prescription Drug was prescribed by a specialist physician. You may access information on which Prescription Drugs are subject to benefit enhancement, reduction or no benefit through the Internet at www.myuhc.com or by calling the telephone number on your ID card.

Rebates and Other Discounts

UnitedHealthcare and Vermilion Parish School Board may, at times, receive rebates for certain drugs on the PDL. UnitedHealthcare does not pass these rebates and other discounts on to you nor does UnitedHealthcare take them into account when determining your Copay.

The Claims Administrator and a number of its affiliated entities, conduct business with various pharmaceutical manufacturers separate and apart from this Prescription Drug section. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Prescription Drug section. The Claims Administrator is not required to pass on to you, and does not pass on to you, such amounts.

Coupons, Incentives and Other Communications

UnitedHealthcare may send mailings to you or your Physician that communicate a variety of messages, including information about Prescription Drugs. These mailings may contain coupons or offers from pharmaceutical manufacturers that allow you to purchase the described Prescription Drug at a discount or to obtain it at no charge. Pharmaceutical manufacturers may pay for and/or provide the content for these mailings. Only your Physician can determine whether a change in your Prescription order or refill is appropriate for your medical condition.

Exclusions - What the Prescription Drug Plan Will Not Cover

Exclusions from coverage listed in Section 8, Exclusions apply also to this section, except that any preexisting condition exclusion in Section 8, Exclusions is not applicable to this section. In addition, the exclusions listed below apply.

When an exclusion applies to only certain Prescription Drugs, you can access www.myuhc.com through the Internet or by calling the telephone number on your ID card for information on which Prescription Drugs are excluded.

Medications that are:

1.   for any condition, Injury, Sickness or mental illness arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received;

2.   any Prescription Drug for which payment or benefits are provided or available from the local, state or federal government (for example Medicare) whether or not payment or benefits are received, except as otherwise provided by law;

3.   Pharmaceutical Products for which Benefits are provided in the medical (not in Section 15, Prescription Drugs) portion of the Plan;

This exclusion does not apply to Depo Provera and other injectable drugs used for contraception.

4.   available over-the-counter that do not require a prescription order or refill by federal or state law before being dispensed, unless the Plan Administrator has designated over-the-counter medication as eligible for coverage as if it were a Prescription Drug and it is obtained with a prescription order or refill from a Physician. Prescription Drugs that are available in over-the-counter form or comprised of components that are available in over-the-counter form or equivalent. Certain Prescription Drugs that the Plan Administrator has determined are Therapeutically Equivalent to an over-the-counter drug. Such determinations may be made up to six times during a calendar year, and the Plan Administrator may decide at any time to reinstate Benefits for a Prescription Drug that was previously excluded under this provision;

5.   Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration and requires a prescription order or refill. Compounded drugs that are available as a similar commercially available Prescription Drug. (Compounded drugs that contain at least one ingredient that requires a prescription order or refill are assigned to ‍Tier-3‍;

6.   dispensed outside of the United States, except in an Emergency;

7.   Durable Medical Equipment (prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered);

8.   for smoking cessation;

9.   growth hormone therapy except as may be provided as a prescription drug benefit for a documented growth hormone deficiency, Turner's Syndrome, growth delay due to cranial radiation, or chronic renal disease;

10.  the amount dispensed (days' supply or quantity limit) which exceeds the supply limit;

11.  the amount dispensed (days' supply or quantity limit) which is less than the minimum supply limit;

12.  certain Prescription Drugs that have not been prescribed by a specialist physician;

13.  certain new drugs and/or new dosages, until they are reviewed and assigned to a tier by the PDL Management Committee;

14.  prescribed, dispensed or intended for use during an Inpatient Stay;

15.  prescribed for appetite suppression, and other weight loss products;

16.  prescribed to treat infertility;

17.  Prescription Drugs, including new Prescription Drugs or new dosage forms, that UnitedHealthcare and Vermilion Parish School Board determines do not meet the definition of a Covered Health Service;

18.  Prescription Drugs when prescribed as sleep aids;

19.  Prescription Drugs that contain (an) active ingredient(s) available in and Therapeutically Equivalent to another covered Prescription Drug;

20.  Prescription Drugs that contain (an) active ingredient(s) which is (are) a modified version of and Therapeutically Equivalent to another covered Prescription Drug;

21.  typically administered by a qualified provider or licensed health professional in an outpatient setting. This exclusion does not apply to Depo Provera and other injectable drugs used for contraception;

22.  in a particular Therapeutic Class (visit  www.myuhc.com or call the ‍‍number on the back of your ID card for information on which Therapeutic Classes are excluded);

23.  unit dose packaging of Prescription Drugs;

24.  used for conditions and/or at dosages determined to be Experimental or Investigational, or Unproven, unless UnitedHealthcare and Vermilion Parish School Board have agreed to cover an Experimental or Investigational or Unproven treatment, as defined in Section 14, Glossary;

25.  used for cosmetic purposes;

26.  vitamins, except for the following which require a prescription:

-        prenatal vitamins;

-        vitamins with fluoride; and

-        single entity vitamins.

Glossary - Prescription Drugs

Brand-name - a Prescription Drug that is either:

      manufactured and marketed under a trademark or name by a specific drug manufacturer; or

      identified by UnitedHealthcare as a Brand-name Drug based on available data resources including, but not limited to, Medi-Span, that classify drugs as either Brand-name or Generic based on a number of factors.

You should know that all products identified as "brand name" by the manufacturer, pharmacy, or your Physician may not be classified as Brand-name by the Claims Administrator.

Designated Pharmacy – a pharmacy that has entered into an agreement with UnitedHealthcare or with an organization contracting on its behalf, to provide specific Prescription Drugs including, but not limited to, Specialty Prescription Drugs. The fact that a pharmacy is a Network Pharmacy does not mean that it is a Designated Pharmacy.

Generic - a Prescription Drug that is either:

      chemically equivalent to a Brand-name drug; or

      identified by UnitedHealthcare as a Generic Drug based on available data resources, including, but not limited to, Medi-Span, that classify drugs as either Brand-name or Generic based on a number of factors.

You should know that all products identified as a "generic" by the manufacturer, pharmacy or your Physician may not be classified as a Generic by the Claims Administrator.

Network Pharmacy - a retail or mail order pharmacy that has:

      entered into an agreement with the Claims Administrator to dispense Prescription Drugs to Covered Persons;

      agreed to accept specified reimbursement rates for Prescription Drugs; and

      been designated by the Claims Administrator as a Network Pharmacy.

PDL - see Prescription Drug List (PDL).

PDL Management Committee - see Prescription Drug List (PDL) Management Committee.

Predominant Reimbursement Rate – the amount the Plan will pay to reimburse you for a Prescription Drug Product that is dispensed at a non-Network Pharmacy. The Predominant Reimbursement Rate for a particular Prescription Drug dispensed at a non-Network Pharmacy includes a dispensing fee and any applicable sales tax. The Claims Administrator calculates the Predominant Reimbursement Rate using its Prescription Drug Charge that applies for that particular Prescription Drug at most Network Pharmacies.

Prescription Drug - a medication, product or device that has been approved by the Food and Drug Administration and that can, under federal or state law, only be dispensed using a prescription order or refill. A Prescription Drug includes a medication that, due to its characteristics, is appropriate for self-administration or administration by a non-skilled caregiver. For purposes of this Plan, Prescription Drugs include:

      insulin;

      the following diabetic supplies:

-        insulin syringes with needles;

-        blood testing strips - glucose;

-        urine testing strips - glucose;

-        ketone testing strips and tablets; and

-        lancets and lancet devices.

Prescription Drug Charge – the rate the Claims Administrator has agreed to pay its Network Pharmacies, including the applicable dispensing fee and any applicable sales tax, for a Prescription Drug dispensed at a Network Pharmacy.

Prescription Drug List (PDL) - a list that categorizes into tiers medications, products or devices that have been approved by the U.S. Food and Drug Administration. This list is subject to periodic review and modification (generally quarterly, but no more than six times per calendar year). You may determine to which tier a particular Prescription Drug has been assigned by contacting UnitedHealthcare at the toll-free ‍‍number on your ID card or by logging onto www.myuhc.com.

Prescription Drug List (PDL) Management Committee - the committee that UnitedHealthcare designates for, among other responsibilities, classifying Prescription Drugs into specific tiers.

Preventive Care Medications - the medications that are obtained at a Network Pharmacy ‍ and that are payable at 100% of the Prescription Drug Charge (without application of any Copayment, Coinsurance, Annual Deductible, Annual Prescription Drug Deductible or Specialty Prescription Drug Annual Deductible) as required by applicable law under any of the following:

·       evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;

·       immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;

·       with respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; or

·       with respect to women, such additional preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

You may determine whether a drug is a Preventive Care Medication through the internet at www.myuhc.com or by calling UnitedHealthcare at the toll-free telephone number on your ID card.

Select Prescription Drug - a Prescription Drug that is generally a tier-3 drug with lower-tiered alternatives used to treat the same condition. For more information, visit myuhc.com or call UnitedHealthcare at the toll-free number on your ID card.

Specialty Prescription Drug - Prescription Drug that is generally high cost, self-injectable, oral or inhaled biotechnology drug used to treat patients with certain illnesses. Specialty Prescription Drugs include certain drugs for Infertility. For more information, visit myuhc.com or call UnitedHealthcare at the toll-free number on your ID card.

Therapeutic Class – a group or category of Prescription Drug with similar uses and/or actions.

Therapeutically Equivalent – when Prescription Drugs have essentially the same efficacy and adverse effect profile.

Usual and Customary Charge – the usual fee that a pharmacy charges individuals for a Prescription Drug without reference to reimbursement to the pharmacy by third parties. The Usual and Customary Charge includes a dispensing fee and any applicable sales tax.

 


ATTACHMENT I - HEALTH CARE REFORM NOTICES

Patient Protection and Affordable Care Act ("PPACA")

Patient Protection Notices

The Claims Administrator generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in the Claims Administrator’s network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the Claims Administrator at the‍‍ number on the back of your ID card.

For children, you may designate a pediatrician as the primary care provider.

You do not need prior authorization from the Claims Administrator or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the Claims Administrator’s network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the Claims Administrator at the‍‍ number on the back of your ID card.

 


ATTACHMENT II - LEGAL  Notices

Women's Health and Cancer Rights Act of 1998

As required by the Women's Health and Cancer Rights Act of 1998, we provide Benefits under the Plan for mastectomy, including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema).

If you are receiving Benefits in connection with a mastectomy, Benefits are also provided for the following Covered Health Services, as you determine appropriate with your attending Physician:

·       All stages of reconstruction of the breast on which the mastectomy was performed;

·       Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

·       Prostheses and treatment of physical complications of the mastectomy, including lymphedema.

The amount you must pay for such Covered Health Services (including Copayments and any Annual Deductible) are the same as are required for any other Covered Health Service. Limitations on Benefits are the same as for any other Covered Health Service.

Statement of Rights under the Newborns' and Mothers' Health Protection Act

Under Federal law, group health Plans and health insurance issuers offering group health insurance coverage generally may not restrict Benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the Plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.

Also, under Federal law, plans and issuers may not set the level of Benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.

In addition, a plan or issuer may not, under Federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on precertification, contact your issuer.

TEXT

 


ADDENDUM - UNITEDHEALTH ALLIES

Introduction

This Addendum to the Summary Plan Description provides discounts for select non-Covered Health Services from Physicians and health care professionals.

When the words "you" and "your" are used the Plan is referring to people who are Covered Persons as the term is defined in the Summary Plan Description (SPD). See Section 14, Glossary in the SPD.

Important:

UnitedHealth Allies is not a health insurance plan. You are responsible for the full cost of any services purchased, minus the applicable discount. Always use your health insurance plan for Covered Health Services described in the Summary Plan Description (see Section 5, Plan Highlights) when a benefit is available.

What is UnitedHealth Allies?

UnitedHealth Allies is a health value program that offers savings on certain products and services that are not Covered Health Services under your health plan.

Because this is not a health insurance plan, you are not required to receive a referral or submit any claim forms.

Discounts through UnitedHealth Allies are available to you and your Dependents as defined in the Summary Plan Description in Section 14, Glossary.

Selecting a Discounted Product or Service

A list of available discounted products or services can be viewed online at www.healthallies.com or by calling the ‍‍‍number on the back of your ID card.

After selecting a health care professional and product or service, reserve the preferred rate and print the rate confirmation letter. If you have reserved a product or service with a ‍customer service representative, the rate confirmation letter will be faxed or mailed to you.

Important:

You must present the rate confirmation at the time of receiving the product or service in order to receive the discount.

Visiting Your Selected Health Care Professional

After reserving a preferred rate, make an appointment directly with the health care professional. Your appointment must be within ninety (90) days of the date on your rate confirmation letter.

Present the rate confirmation and your ID card at the time you receive the service. You will be required to pay the preferred rate directly to the health care professional at the time the service is received.

Additional UnitedHealth Allies Information

Additional information on the UnitedHealth Allies program‍ can be obtained online at www.healthallies.com or by calling the toll-free ‍‍phone number on the back of your ID card.


ADDENDUM - PARENTSTEPS®

Introduction

This Addendum to the Summary Plan Description illustrates the benefits you may be eligible for under the ParentSteps program.

When the words "you" and "your" are used the Plan is referring to people who are Covered Persons as the term is defined in the Summary Plan Description (SPD). See Section 14, Glossary in the SPD.

Important:

ParentSteps is not a health insurance plan. You are responsible for the full cost of any services purchased. ParentSteps will collect the provider payment from you online via the ParentSteps website and forward the payment to the provider on your behalf. Always use your health insurance plan for Covered Health Services described in the Summary Plan Description 5, Plan Highlights) when a benefit is available.

What is ParentSteps?

ParentSteps is a discount program that offers savings on certain medications and services for the treatment of infertility that are not Covered Health Services under your health plan.

This program also offers:

      guidance to help you make informed decisions on where to receive care;

      education and support resources through experienced infertility nurses;

      access to providers contracted with UnitedHealthcare that offer discounts for infertility medical services; and

      discounts on select medications when filled through a designated pharmacy partner.

Because this is not a health insurance plan, you are not required to receive a referral or submit any claim forms.

Discounts through this program are available to you and your Dependents. Dependents are defined in the Summary Plan Description in Section 14, Glossary.

Registering for ParentSteps

Prior to obtaining discounts on infertility medical treatment or speaking with an infertility nurse you need to register for the program online at www.myoptumhealthparentsteps.com or by calling ParentSteps toll-free at 1-877-801-3507.

Selecting a Contracted Provider

After registering for the program you can view ParentSteps facilities and clinics online based on location, compare IVF cycle outcome data for each participating provider and see the specific rates negotiated by ParentSteps with each provider for select types of infertility treatment in order to make an informed decision.

Visiting Your Selected Health Care Professional

Once you have selected a provider, you will be asked to choose that clinic for a consultation.  You should then call and make an appointment with that clinic and mention you are a ParentSteps member. ParentSteps will validate your choice and send a validation email to you and the clinic.

Obtaining a Discount

If you and your provider choose a treatment in which ParentSteps discounts apply, the provider will enter in your proposed course of treatment. ParentSteps will alert you, via email, that treatment has been assigned. Once you log in to the ParentSteps website, you will see your treatment plan with a cost breakdown for your review.

After reviewing the treatment plan and determining it is correct you can pay for the treatment online.  Once this payment has been made successfully ParentSteps will notify your provider with a statement saying that treatments may begin.

Speaking with a Nurse

Once you have successfully registered for the ParentSteps program you may receive additional educational and support resources through an experienced infertility nurse. You may even work with a single nurse throughout your treatment if you choose.

For questions about diagnosis, treatment options, your plan of care or general support, please contact a ParentSteps nurse via phone (toll-free) by calling 1-866-774-4626.

ParentSteps nurses are available from 8 a.m. to 5 p.m. Central Time; Monday through Friday, excluding holidays.

Additional ParentSteps Information

Additional information on the ParentSteps program can be obtained online at www.myoptumhealthparentsteps.com or by calling 1-877-801-3507 (toll-free).

 



***Inside Back Cover