UNICARE STATE INDEMNITY PLAN/BASIC MEMBERHANDBOOK
For non-Medicare retirees participating in the RetiredMunicipal Teacher Program andthe ElderlyGovernmental Retiree Program
Effective July 1, 2017
Basic Plan Handbook for RMT / EGR (2017-2018)Series 1 - 10/16/1810/16/2018 5:12 PM 1
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 ().
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.
Basic Plan Handbook for RMT / EGR (2017-2018)Series 1 - 10/16/1810/16/2018 5:12 PM 1
Interpreting and Translating Services
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 112 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.
Basic Plan Handbook for RMT / EGR (2017-2018)Series 1 - 10/16/1810/16/2018 5:12 PM 1
Table of Contents
Table of Contents
Disclosure when Plan Meets Minimum Standards
Interpreting and Translating Services
Who to Contact
Part1: Your Medical Plan
Describes the benefits for medical services, treatment and supplies. Thesebenefits are insured and administered by the UniCare State IndemnityPlan.
1:Getting started with Basic
Introducing your medical plan
Prescription drugs and behavioral health
Physicians in Massachusetts
Using this handbook
What the handbook symbols mean
Do you have other health insurance?
About your ID cards
Medical services that need to be preapproved
Notification requirements for preapprovals
2:What to know about costs
What member costs are (cost sharing)
How member costs work
About your medical deductible
About copays
About coinsurance
Limits to your member costs
About allowed amounts
About balance billing
About preferred vendors
3:Find out what’s covered
Summary of benefits
Allergy shots
Ambulances
Anesthesia
Autism spectrum disorders
Behavioral health services
Cardiac rehabilitation (rehab) programs
Chemotherapy
Chiropractic care
Circumcision
Cleft lip and cleft palate
Clinical trials (clinical research studies)
Dental services
Diabetes care
Diabetes supplies
Dialysis
Doctor and other health care provider services
Drug screening (lab tests)
Durable medical equipment (DME)
Early intervention programs
Emergency care / urgent care
Enteral therapy
Eye care
Eyeglasses and contact lenses
Family planning and hormone replacement
Fitness club reimbursement
Foot care (routine)
Formulas (special)
Gynecology exams
Hearing aids
Hearing exams
Home health care
Home infusion therapy
Hospice and end-of-life care
Hospital admissions (inpatient)
Immunizations (vaccines)
Infertility treatment
Laboratory services (lab work)
Long-term care facilities
Maternity services
Medical services (not otherwise specified)
Neuropsychological (neuropsych) testing
Nutritional counseling
Occupational therapy
Outpatient hospital services (not otherwise specified)
Oxygen
Palliative care
Personal Emergency Response Systems (PERS)
Physical therapy
Prescription drugs
Preventive care
Private duty nursing
Prosthetics and orthotics
Radiation therapy
Radiology and imaging services
Rehabilitation (rehab) hospitals
Retail health clinics
Skilled nursing facilities
Sleep studies
Speech therapy
Surgery
Tobacco cessation counseling
Transplants
Travel clinics
Urgent care
Walk-in clinics
Wigs
Schedule of preventive services
4:Coverage that is excluded or limited
5:About your plan and coverage
How to use your plan wisely
Types of health care providers
How to find providers
About physician tiering
How UniCare reimburses providers
How to submit a claim
Deadlines for filing claims
Checking your claims for billing accuracy
About claim reviews
Deadlines on bringing legal action
Right of reimbursement
About your privacy rights
About your appeal rights
Involuntary disenrollment rate
Reporting requirements
About the review process for preapprovals
Getting support for serious medical issues
6:About enrollment and membership
Free or low-cost health coverage for children and families
Eligibility for benefits
Application for coverage
When coverage begins
When coverage ends for enrollees
When coverage ends for dependents
Disenrollment
Continuation of coverage for Massachusettsresidents
Duplicate coverage
Special enrollment condition
Continuing coverage
Group health continuation coverage under COBRA
Conversion to non-group health coverage
Coordinating benefits with other health plans (COB)
7:How to get more information
Who to contact (and for what)
Contacting the UniCare Customer Service Center
Using the unicarestateplan.com website
Using the 24/7 NurseLine
How to ask for a claim review
How to check on your claims
How to ask to have medical information released
The Patients’ Bill of Rights and Office of Patient Protection
8:Plan Definitions
Part2: Your Prescription Drug Plan
Describes the benefits for prescription drugs. Thesebenefitsare administeredbyCVSCaremark.
About Your Plan
Copayments and Deductible
Out-of-Pocket Limit
How to Use the Plan
Claim Forms
Other Plan Provisions
Exclusions
Definitions
Member Appeals
Health and Prescription Information
Part3: Your Behavioral Health Plan
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
How to Contact Beacon Health Options
How to Get Optimal Benefits
Referral/Prior Authorization for EAP and Non-Routine Services
Emergency Care
Urgent Care
Routine Care
Confidentiality
Coordination of Benefits
Part II – Benefits
Benefits Explained
WhatThis Plan Pays: Summary of Covered Services
Covered Services
Telehealth Services
Enrollee Assistance Program (EAP)
Case Management
What’s Not Covered – Exclusions
Part III – Definitions, Appeals, Complaints and Grievances
Definitions of Beacon Health Options Behavioral Health Terms
Filing Claims
Complaints
Appeals
Appendices
AppendixA: GIC Notices
Important notice from the GIC about your prescriptiondrug coverage
and Medicare
The Uniformed Services Employment and Reemployment RightsAct
(USERRA)
AppendixB: Privacy Notices
UniCare’s HIPAA Notice of Privacy Practices
Maine notice of additional privacy rights
AppendixC: Forms
Fitness Club Reimbursement Form
Bill Checker Program Form
AppendixD: Federal and State Mandates
Premium assistance under Medicaid and the Children’s Health Insurance Program(CHIP)
Coverage for reconstructive breast surgery
Minimum maternity confinement benefits
Mental health parity
AppendixE: Your Right to Appeal
Inquiry process
Grievances/appeals process
Time requirements for resolution of grievances/appeals
Expedited grievance/appeal process
How to file an inquiry, complaint or grievance/appeal
External review process
Expedited external review process
Index
Get help in your language
Notice of nondiscrimination
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Table of Contents
List of Tables
Table1...... Notification Requirements for Preapprovals
Table 2.Medical Deductible Amounts
Table 3.Copays for Office Visits
Table 4.Copays for Other Medical Services
Table 5.Out-of-Pocket Limit
Table 6.Summary of Covered Services
Table7...... Example Conditions for Urgent Care
Table8...... Examples of Covered Inpatient Services
Table 9.Preventive Care Schedule
Table 10.How to Get the Most Out of Basic
Table 11.Deductible for Prescription Drugs
Table 12.Copayments for Prescription Drugs
Table 13.Out-of-Pocket Limit
Table 14.Claims Reimbursement
Table 15.Current Examples of Drugs Requiring Prior Authorization for
Specific Conditions
Table 16.Current Examples of Top Drug Classes that May Require Prior
Authorization for Medical Necessity
Table 17.Mental Health, Substance Use Disorder, and EAP Benefits
Table 18.Summary of Covered Services
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Table of Contents
Part1:Your Medical Plan
Description of Benefits
This is the Certificate of Insurance for Elderly Governmental Retirees and RetiredMunicipal Teachers who are not eligible for Medicare. Coverage is providedunderGroup Policy Number GI131192, under which UniCare LifeHealthInsuranceCompany is the insurer and the Group Insurance CommissionoftheCommonwealthofMassachusetts is the plan sponsor.
For questions about any of the information in Part 1 of this handbook, pleasecontactUniCare at 800-442-9300.
Administered by
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Schedule of preventive services3:Find out what’s covered
1:Getting started with Basic
This handbook is a guide to benefits for you and your dependents covered under UniCare State Indemnity Plan/Basic. These benefits are provided under Group Insurance Policy GI 131192, insured by UniCare Life and Health Insurance Company. The Group Insurance Commission (GIC) of the Commonwealth of Massachusetts is the plan sponsor.
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/Basicoffers 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.
The Plan provides all health care services and benefits you are entitled to on a nondiscriminatory basis, including benefits mandated by state or federal law.
The Plan provides you with freedom of choice in selecting your physicians, including coverage for pediatric medical specialty. The Plan will provide coverage for pediatric specialty care, including mental health care, to individuals requiring such services.
The UniCare State Indemnity Plan does not exclude pre-existing conditions.
Part1 of this handbook (pages 11-119) 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
Your prescription drug benefits are administered by CVS Caremark. These benefits are described in Part2 of this handbook (pages 121-137).
Your behavioral health benefits are insured 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 139-166). You can also call Beacon toll free at 855-750-8980 for details about your coverage.
Physicians in Massachusetts
For additional information about practicing physicians in Massachusetts, contact the Massachusetts Board of Registration in Medicine at 8003770550 or via their website at massmedboard.org.
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 Chapter4.
Needs preapproval – You (or someone acting for you) must tell UniCare if you are having this service or procedure. Ifyou don’t do so, your benefits may be reduced by up to $500. See “Medical services that need to be preapproved” on page 15 for details about this requirement.
Use UniCare preferred vendors– To get the best benefit, use a UniCare preferred vendor for this service or product. See page 27 to learn more.
Check the website – Information about this topic can be found at unicarestateplan.com.
Do you have other health insurance?
If you or a family member is covered underanother health plan, you must tell UniCare. If you haven’t already done so, be sure to fill out and return the Other Health Insurance (OHI) form. However, youdon’t need to send in the OHI form if your other coverage is from one of the following:
AARP
MassHealth
TRICARE
If you have health coverage from any other insurer and haven’t yet sent in the OHI form, please call UniCare Customer Service at 800-442-9300 and ask that the form be sent to you. Or, you can download it from unicarestateplan.com.
To learn more about how UniCare coordinates benefits with other health plans, turn to “Coordinating benefits with other health plans (COB)” on page 105.
About your ID cards
When you enroll in the Plan, you will get either one or two UniCare ID cards, depending on where you live. These cards have useful information about your benefits, as well as important telephone numbers you and your health care providers may need.
If you lose yourUniCare ID card or need additional cards, you can order them from unicarestateplan.com. Or,callUniCare Customer Service at 800-442-9300 for help.
Prescription drug cards – CVS Caremark will send your prescription drug cards ina separate mailing. Call CVSat 877-876-7214 if you have any questions about your prescription drug card.
If you live in Massachusetts
Massachusetts residents get a blue UniCare ID card. Use this card any time you get medical care, both inMassachusetts and when you travel.
If you live outside of Massachusetts
To get the best coverage, members who live outside of Massachusetts should always use network providers in the states where they live (their home states). Although your care is covered at other providers, non-network providers may balance bill you for charges above what the Plan pays. See page 26 to find out more about balancebilling.
Members who live outside of Massachusetts get two cards when they enroll in the Plan: a blue UniCare ID card and a green network card.
When you get care at home –Use your green network card when you get medical care from network providers in your home state.
When you travel – Use your blue UniCare ID card if you need urgent care when traveling outside your home state.
In Massachusetts – Use your blue UniCare ID card to get medical care in Massachusetts.
Medical services that need to be preapproved
Preapproval confirms that a service you’re going to have is eligible for benefits. By getting a service preapproved, you reduce your risk of having to pay for a service that isn’t covered.
If you are scheduled to have one of the services listed in Table1, you (or someone acting for you) must contact UniCare ahead of time. This notification is required to ensure that there’s enough time for the preapproval review to take place. Table1 shows how much advance notice is required for each service.