UNICARE STATE INDEMNITY PLAN/BASIC MEMBERHANDBOOK
For active employees and non-Medicare retirees
Effective July 1, 2017
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Disclosure when Plan Meets Minimum Standards
This health plan meets the Minimum Creditable Coverage standards
and will satisfy the individual mandate that you have health insurance.
Please see additional information below.
MASSACHUSETTS REQUIREMENT TO PURCHASE HEALTH INSURANCE:
As of January 1, 2008, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement based on affordability or individual hardship. For more information call the Connector at 877MAENROLL or visit the Connector website (www.mahealthconnector.org).
This health plan meets the Minimum Creditable Coverage standards that became effective July1,2008 as part of the Massachusetts Health Care Reform Law. If you are covered under this plan, you will satisfy the statutory requirement that you have health insurance meeting these standards.
This Disclosure is for the Minimum Creditable Coverage Standards that are effective January 1, 2017. Because these standards may change, review your Health Plan Materials each year to determine whether your Health Plan meets the latest standards.
If you have questions about this notice, you may contact the Division of Insurance by calling 617521-7794 or visiting its website at mass.gov/doi.
Interpreting and Translating Services
If you need a language interpreter when you call UniCare Customer Service, a customer service representative will access a language line and connect you with an interpreter who will translate your conversation with the representative.
If you use a TTY machine, you can reach UniCare by calling 711.
Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio al cliente que aparece al dorso de sutarjeta de identificación o en elfolleto de inscripción.
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Who to Contact
For questions about your medical planUniCare State Indemnity Plan
Customer Service Center
P.O. Box 9016
Andover, MA 01810-0916
800-442-9300 (toll free)
TTY: 711
unicarestateplan.com / § What your benefits are for a particular medical service orprocedure
§ The status of (or a question about) a medical claim
§ How to find a doctor, hospital or other medical provider
§ Information in “Your Medical Plan” (Part1ofthishandbook)
For questions about your prescription drug plan
CVS Caremark
877-876-7214 (toll free)
TTY: 800-238-0756
caremark.com / § What your benefit is for a prescription drug
§ The status of (or a question about) a prescription drug claim
§ Where to get prescriptions filled
§ Which drugs are covered
§ Information in “Your Prescription Drug Plan” (Part2of this handbook)
For questions about your behavioral health plan
Beacon Health Options
855-750-8980 (toll free)
TTY: 711
beaconhealthoptions.com/gic / § What your benefits are for mental health services
§ What your benefits are for substance use disorder services
§ What your benefits are for the Enrollee Assistance Program (EAP)
§ The status of (or a question about) a mental health, substanceuse disorder, or EAP claim
§ Information in “Your Behavioral Health Plan” (Part3of this handbook)
For general health questions after hours (not about plan benefits or coverage)
24/7 NurseLine
800-424-8814 (toll free)
Select the NurseLine option / § How to prepare for an upcoming medical procedure
§ What side effects are possible from your medication
§ Whether to go to an urgent care center or call your doctor
§ See page 4 for more information
For other questions, such as questions about premiums or participation in any Group Insurance Commission (GIC) programs, please see your GIC coordinator or contact the GIC.
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Table of Contents
Disclosure when Plan Meets Minimum Standards 2
Interpreting and Translating Services 2
Who to Contact 3
Part1: Your Medical Plan 11
Describes the benefits for medical services, treatment and supplies. Thesebenefits are administered by the UniCare State IndemnityPlan.
1: Getting started with Basic 12
Introducing your medical plan 12
Prescription drugs and behavioral health 12
Using this handbook 13
What the handbook symbols mean 13
Do you have other health insurance? 13
About your ID cards 14
Medical services that need to be preapproved 15
Notification requirements for preapprovals 17
2: What to know about costs 20
What member costs are (cost sharing) 20
How member costs work 20
About your medical deductible 21
About copays 22
About coinsurance 25
Limits to your member costs 25
About allowed amounts 25
About balance billing 26
About preferred vendors 27
3: Find out what’s covered 28
Summary of benefits 28
Allergy shots 33
Ambulances 33
Anesthesia 33
Autism spectrum disorders 34
Behavioral health services 34
Cardiac rehabilitation (rehab) programs 34
Chemotherapy 35
Chiropractic care 35
Circumcision 35
Cleft lip and cleft palate 35
Clinical trials (clinical research studies) 36
Dental services 38
Diabetes care 39
Diabetes supplies 39
Dialysis 40
Doctor and other health care provider services 41
Drug screening (lab tests) 42
Durable medical equipment (DME) 42
Early intervention programs 44
Emergency care / urgent care 44
Enteral therapy 46
Eye care 46
Eyeglasses and contact lenses 47
Family planning 47
Fitness club reimbursement 48
Foot care (routine) 48
Gynecology exams 49
Hearing aids 49
Hearing exams 49
Home health care 50
Home infusion therapy 51
Hospice and end-of-life care 51
Hospital admissions (inpatient) 53
Immunizations (vaccines) 55
Infertility treatment 55
Laboratory services (lab work) 56
Long-term care facilities 56
Maternity services 57
Medical services (not otherwise specified) 57
Neuropsychological (neuropsych) testing 57
Nutritional counseling 57
Occupational therapy 58
Outpatient hospital services (not otherwise specified) 58
Oxygen 58
Palliative care 59
Personal Emergency Response Systems (PERS) 59
Physical therapy 60
Prescription drugs 61
Preventive care 61
Private duty nursing 61
Prosthetics and orthotics 62
Radiation therapy 63
Radiology and imaging services 63
Rehabilitation (rehab) hospitals 63
Retail health clinics 64
Skilled nursing facilities 64
Sleep studies 64
Speech therapy 64
Surgery 65
Tobacco cessation counseling 67
Transplants 68
Travel clinics 69
Urgent care 69
Walk-in clinics 69
Wigs 69
Schedule of preventive services 70
4: Coverage that is excluded or limited 74
5: About your plan and coverage 84
How to use your plan wisely 84
Types of health care providers 85
How to find providers 88
About physician tiering 88
How UniCare reimburses providers 90
How to submit a claim 90
Deadlines for filing claims 91
Checking your claims for billing accuracy 91
About claim reviews 92
Deadlines on bringing legal action 92
Right of reimbursement 92
About your privacy rights 93
About your appeal rights 93
About the review process for preapprovals 93
Getting support for serious medical issues 94
6: About enrollment and membership 95
Free or low-cost health coverage for children and families 95
Application for coverage 95
When coverage begins 95
When coverage ends for enrollees 96
When coverage ends for dependents 96
Duplicate coverage 96
Special enrollment condition 96
Continuing coverage upon termination of employment 96
Group health continuation coverage under COBRA 98
Conversion to non-group health coverage 102
Coordinating benefits with other health plans (COB) 103
7: How to get more information 107
Who to contact (and for what) 107
Contacting the UniCare Customer Service Center 108
Using the unicarestateplan.com website 109
Using the 24/7 NurseLine 110
How to ask for a claim review 111
How to check on your claims 111
How to ask to have medical information released 111
8: Plan Definitions 112
Part2: Your Prescription Drug Plan 117
Describes the benefits for prescription drugs. Thesebenefitsare administeredbyCVSCaremark.
About Your Plan 118
Copayments and Deductible 119
Out-of-Pocket Limit 120
How to Use the Plan 120
Claim Forms 123
Other Plan Provisions 124
Exclusions 128
Definitions 128
Member Appeals 130
Health and Prescription Information 133
Part3: Your Behavioral Health Plan 135
Describes the benefits for mental health, substance use disorder and theEnrollee Assistance Program. These benefits are administered by BeaconHealthOptions.
Part I – How to Use this Plan 136
How to Contact Beacon Health Options 136
How to Get Optimal Benefits 136
Referral/Prior Authorization for EAP and Non-Routine Services 137
Emergency Care 137
Urgent Care 138
Routine Care 138
Confidentiality 138
Coordination of Benefits 138
Part II – Benefits 139
Benefits Explained 139
WhatThis Plan Pays: Summary of Covered Services 143
Covered Services 147
Telehealth Services 149
Enrollee Assistance Program (EAP) 150
Case Management 152
What’s Not Covered – Exclusions 152
Part III – Definitions, Appeals, Complaints and Grievances 156
Definitions of Beacon Health Options Behavioral Health Terms 156
Filing Claims 158
Complaints 159
Appeals 159
Appendices 163
AppendixA: GIC Notices 164
Notice of Group Insurance Commission (GIC) Privacy Practices 164
Important notice from the GIC about your prescriptiondrug coverage
and Medicare 167
The Uniformed Services Employment and Reemployment RightsAct
(USERRA) 169
AppendixB: Forms 170
Fitness Club Reimbursement Form 171
Bill Checker Program Form 172
AppendixC: Federal and State Mandates 173
Premium assistance under Medicaid and the Children’s Health Insurance Program(CHIP) 173
Coverage for reconstructive breast surgery 177
Minimum maternity confinement benefits 177
AppendixD: Your Right to Appeal 178
Notice of adverse benefit determination 178
Appeals 179
How your appeal will be decided 180
Notification of the outcome of the appeal 180
Appeal denial 181
External review 181
Requirement to file an appeal before filing a lawsuit 182
Index 183
Get help in your language 188
Notice of nondiscrimination 189
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Table of Contents
List of Tables
Table1. Notification Requirements for Preapprovals 17
Table 2. Medical Deductible Amounts 21
Table 3. Copays for Office Visits 24
Table 4. Copays for Other Medical Services 24
Table 5. Out-of-Pocket Limit 25
Table 6. Summary of Covered Services 28
Table7. Example Conditions for Urgent Care 45
Table8. Examples of Covered Inpatient Services 54
Table 10. Preventive Care Schedule 70
Table 11. How to Get the Most Out of Basic 84
Table 12. Deductible for Prescription Drugs 119
Table 13. Copayments for Prescription Drugs 119
Table 14. Out-of-Pocket Limit 120
Table 15. Claims Reimbursement 123
Table 16. Current Examples of Drugs Requiring Prior Authorization for
Specific Conditions 126
Table 17. Current Examples of Top Drug Classes that May Require Prior
Authorization for Medical Necessity 126
Table 18. Mental Health, Substance Use Disorder, and EAP Benefits 141
Table 19. Summary of Covered Services 143
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Part1:Your Medical Plan
Description of Benefits
For questions about any of the information in Part 1 of this handbook, pleasecontactUniCare at 800-442-9300.
Administered by
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Notification requirements for preapprovals 1: Getting started with Basic
1: Getting started with Basic
This handbook is a guide to benefits for you and your dependents covered under UniCare State Indemnity Plan/Basic (the Basic plan). These benefits are provided through the Group Insurance Commission (GIC), thestate agency responsible for the design and payment of all benefits for state, participating municipalities and other governmental entities’ employees and retirees. This Plan is funded by the Commonwealth of Massachusetts and administered by UniCare.
UniCare provides administrative services for UniCare State Indemnity Plan/Basic – including claims processing, customer service, preapproval reviews and case management – at its Customer Service Center in Andover, Massachusetts. UniCare is not the fiduciary or the insurer of UniCare State Indemnity Plan/Basic.
Read this handbook carefully to fully understand your benefits. If you have questions about any of your benefits, see the contact information on page 3.
Introducing your medical plan
UniCare State Indemnity Plan/Basic offers comprehensive coverage anywhere in the world for many health services including hospital stays, surgery, emergency care, preventive care, outpatient services and other medically necessary treatment. You can get services from any provider, anywhere inthe world. Keep in mind, however, that benefits differ depending on the service and the provider, andthat not all services are covered by the Plan.
Part1 of this handbook (pages 11-116) describes your coverage for medical services, and provides information about two different medical plan designs:
1. UniCare State Indemnity Plan/Basic with CIC (Comprehensive Insurance Coverage) isacomprehensive plan that provides benefits for most services at 100% coverage after the applicable copay and/or deductible.
2. UniCare State Indemnity Plan/Basic without CIC is a less comprehensive plan that provides benefits for many services at 80% coverage after the applicable copay and/or deductible.
Prescription drugs and behavioral health
q Your prescription drug benefits are administered by CVS Caremark. These benefits are described in Part2 of this handbook (pages 117-133).
q Your behavioral health benefits are administered by Beacon Health Options. These benefits include coverage for mental health, substance use disorder and the Enrollee Assistance Program (EAP). They are described in Part3 of this handbook (pages 135-162).
Using this handbook
Throughout this handbook, UniCare State Indemnity Plan/Basic is referred to by its full name, oras the UniCare State Indemnity Plan, the Basic plan, or the Plan. The Group Insurance Commission is referred to either by its full name or as the GIC. In addition, the term “you” used inthis handbook also includes your covered dependents.
What the handbook symbols mean
Important information – Pay particular attention to this information because it may have an impact on your benefits.
No coverage, limited coverage, or benefit restriction – There is a limitation, exclusion or some other restriction on this benefit. Afull list of benefit restrictions appears in Chapter 4.