UNiCAre STATe iNDeMNiTY PLAN COMMUNiTY CHOiCe - PDF

Document Sample
UNiCAre STATe iNDeMNiTY PLAN COMMUNiTY CHOiCe - PDF Powered By Docstoc
					                                         Seri eS 5




UNiCAre STATe iNDeMNiTY PLAN
           COMMUNiTY CHOiCe
       Member Handbook for Active Employees and
                         Non-Medicare Retirees




                            Effective July 1, 2011
Table of Contents


Part 1: Medical Plan
Welcome to the UniCare State Indemnity Plan/Community Choice ..............                                               1
 How This Handbook Is Organized .................................................................                         1
 About Your Medical Plan .................................................................................                1
 How to Get the Highest Level of Benefits from Your Medical Plan .............                                            2
 Online Access to Medical Information and Plan Resources
  at www.unicarestateplan.com........................................................................                     3
 MedCall 24/7 Nurse Information Line ...........................................................                          4
Important Plan Information ...............................................................................                4
  Overview............................................................................................................    4
  The Andover Service Center ............................................................................                 4
  Your Identification Card ...................................................................................            5
  Interpreting and Translating Services .............................................................                     5
  Notice of Privacy Practices ...............................................................................             6
  Important Contact Information ......................................................................                    6
Your Costs ...........................................................................................................    6
  Overview............................................................................................................    6
  Calendar Year Deductible.................................................................................               6
  Copayments ......................................................................................................       8
  Coinsurance ......................................................................................................     12
  Out-of-Pocket Maximum ..................................................................................               12
  Allowed Amount...............................................................................................          12
  Charges above the Allowed Amount ...............................................................                       12
  Provider Reimbursement.................................................................................                13
  Physician Tiering ..............................................................................................       13
Your Claims ..........................................................................................................   14
  Overview............................................................................................................   14
  How to Submit a Claim ...................................................................................              14
  Checking Your Claims for Billing Accuracy ...................................................                          15
  Claims Review Process ....................................................................................             16
  Restrictions on Legal Action ............................................................................              16
  Right of Reimbursement .................................................................................               16
  Claims Inquiry ..................................................................................................      16
  Coordination of Benefits (COB) ......................................................................                  16
  Modification of COB Provisions for Persons Enrolled in Medicare
   Parts A and/or B.............................................................................................         18
  Appeal Rights ....................................................................................................     19
  Request and Release of Medical Information.................................................                            19




                                                                                          21769MAMENUNC 10/11
Table of Contents


Managed Care Program ......................................................................................                20
 Overview............................................................................................................      20
 Managed Care Notification Requirements .....................................................                              20
 Utilization Management Program ..................................................................                         24
 Medical Case Management Program ..............................................................                            26
 Quality Centers and Designated Hospitals for Transplants ..........................                                       27
Benefit Highlights ...............................................................................................         28
 A Summary of Your Medical Benefits .............................................................                          28
 Inpatient Hospital Services..............................................................................                 29
 Select Complex Inpatient Procedures and Neonatal ICUs............................                                         29
 Transplants ........................................................................................................      30
 Other Inpatient Facilities .................................................................................              30
 Coronary Artery Disease (CAD) Secondary Prevention Program .................                                              30
 Outpatient Hospital Services ...........................................................................                  31
 Physician Services ............................................................................................           32
 Physical Therapy and Occupational Therapy .................................................                               32
 Preventive Care .................................................................................................         33
 Licensed Retail Medical Clinics at Retail Pharmacies ...................................                                  33
 Family Planning Services .................................................................................                33
 Diagnostic Laboratory Tests (non-hospital based) ..........................................                               33
 Radiology (non-hospital based) .......................................................................                    33
 Private Duty Nursing........................................................................................              34
 Home Health Care ...........................................................................................              34
 Home Infusion Therapy ..................................................................................                  34
 Hospice .............................................................................................................     34
 Early Intervention Services for Children ........................................................                         35
 Ambulance ........................................................................................................        35
 Durable Medical Equipment............................................................................                     35
 Hospital-Based Personal Emergency Response Systems (PERS) .................                                               36
 Prostheses .........................................................................................................      36
 Braces ................................................................................................................   36
 Hearing Aids .....................................................................................................        36
 Eyeglasses / Contact Lenses.............................................................................                  36
 Routine Eye Examinations ...............................................................................                  36
 All Other Covered Medical Services ................................................................                       36
Description of Covered Services .........................................................................                  37
 Inpatient Hospital Services..............................................................................                 37
 Services at Other Inpatient Facilities ..............................................................                     37
 Emergency Treatment for an Accident or Sudden/Serious Illness...............                                              38
 Surgical Services ...............................................................................................         38
 Medical Services ...............................................................................................          39
 Transplants ........................................................................................................      43
 Hospice Care Services ......................................................................................              43
 Hospital-Based Personal Emergency Response Systems (PERS) .................                                               44
 Durable Medical Equipment (DME) ...............................................................                           44
 Coverage for Clinical Trials for Cancer ...........................................................                       45
Table of Contents


Exclusions.............................................................................................................    46
Limitations ...........................................................................................................    49
Plan Definitions ...................................................................................................       51
General Provisions...............................................................................................          59
 Free or Low-Cost Health Coverage to Children and Families .......................                                         59
 Application for Coverage ..................................................................................               59
 When Coverage Begins ....................................................................................                 59
 Continued Coverage .........................................................................................              59
 When Coverage Ends for Enrollees.................................................................                         60
 When Coverage Ends for Dependents ............................................................                            60
 Duplicate Coverage...........................................................................................             60
 Special Enrollment Condition .........................................................................                    60
 Continuing Coverage .......................................................................................               60
 Group Health Continuation Coverage under COBRA Election Notice ........                                                   62
 Conversion to Non-Group Health Coverage...................................................                                65

Part 2: Prescription Drug Plan
CVS Caremark .....................................................................................................         67

Part 3: Mental Health, Substance Abuse and
Enrollee Assistance Programs
United Behavioral Health....................................................................................               79

Appendices
Appendix A: GIC Notices ....................................................................................              100
 Notice of Group Insurance Commission Privacy Practices ..........................                                        100
 Important Notice from the Group Insurance Commission (GIC) about
   Your Prescription Drug Coverage and Medicare .........................................                                 102
 Important Information from the Group Insurance Commission about
   Your HIPAA Portability Rights .....................................................................                    104
 The Uniformed Services Employment and Reemployment Rights Act ......
   (USERRA).......................................................................................................        105
 Notice about the Federal Early Retiree Reinsurance Program ......................                                        106
Appendix B: Disclosure when Plan Meets Minimum Standards ..................... 107
Appendix C: Community Choice Hospital Listing ............................................ 108
Appendix D: Designated Hospitals for Select Complex Inpatient
 Procedures and Neonatal ICUs ....................................................................... 111
Appendix E: Claim Form ..................................................................................... 113
Appendix F: Bill Checker Program ..................................................................... 115
Table of Contents


Appendix G: Federal and State Mandates ..........................................................       116
 Medicaid and the Children’s Health Insurance Program (CHIP)
   Offer Free or Low-Cost Health Coverage to Children and Families ...........                          116
 Coverage for Reconstructive Breast Surgery ..................................................          120
 Minimum Maternity Confinement Benefits ..................................................              120
Appendix H: Your Right to Appeal ..................................................................... 121
Appendix I: Preventive Care Schedule ............................................................... 125
Appendix J: Preferred Vendors ........................................................................... 129

Index

Important Telephone Numbers (toll free)
Medical Benefits                    Prescription                        Mental Health
UniCare State                       Drug Benefits                       and Substance Abuse
Indemnity Plan                      CVS Caremark                        Benefits and Enrollee
(800) 442-9300                      (877) 876-7214                      Assistance Programs
TDD: (800) 322-9161                 TDD: (800) 238-0756                 United Behavioral Health
                                                                        (888) 610-9039
                                                                        TDD: (800) 842-9489


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 su tarjeta de
identificación o en el folleto de inscripción.
 Welcome to the UniCare State Indemnity
 Plan/Community Choice
This Handbook is a guide to benefits for you and your covered dependent(s) under the UniCare State
Indemnity Plan/Community Choice (the Community Choice Plan). These benefits are provided through the
Group Insurance Commission (GIC), the state agency responsible for the design and payment of all benefits
for state, municipal 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 the UniCare State Indemnity Plan/Community Choice –
including claims processing, customer service, utilization management and medical case management –
at its Andover Service Center in Andover, Massachusetts. UniCare is not the fiduciary or the insurer of the
UniCare State Indemnity Plan/Community Choice.
Throughout this Handbook, the UniCare State Indemnity Plan/Community Choice is referred to either by
its full name, as the “UniCare State Indemnity Plan,” as the “Community Choice Plan” or as the “Plan.”
The Group Insurance Commission is referred to either by its full name or as the “GIC.” In addition, the term
“you” used in this Handbook also includes your covered dependent(s).
To fully understand your benefits, please read this Handbook carefully.


How This Handbook Is Organized                           If you have questions about any of your benefits,
                                                         please refer to the contact information on page 6.
Descriptions of the benefits available to you and
your covered dependent(s) are provided in the            About Your Medical Plan
following three parts of this Handbook:
                                                         The UniCare State Indemnity Plan/Community
Part 1: Medical Plan                                     Choice provides comprehensive coverage for many
This part of the Handbook, which begins on               health services including hospital stays, surgery,
this page, describes the benefits available under        emergency care, preventive care, outpatient services
the Community Choice Plan for medical                    and other medically necessary treatment. It is
services, treatment and supplies. These benefits         important to keep in mind that benefits differ
are administered by UniCare.                             depending on the service and the provider, and
Part 2: Prescription Drug Plan                           that not all services are covered under the Plan.
This part of the Handbook describes the prescription     The UniCare State Indemnity Plan/Community
drug benefits, which are administered by                 Choice does not exclude pre-existing conditions.
CVS Caremark. See page 67.
                                                         Physician Services
Part 3: Mental Health, Substance Abuse and               As a Community Choice member, you can see any
Enrollee Assistance Programs                             physician at the same benefits level after the
This part of the Handbook describes the Mental           applicable copay. You will pay lower office visit
Health, Substance Abuse and Enrollee Assistance          copays when you use Tier 1 and Tier 2 physicians
Programs for the Community Choice Plan, which            in Massachusetts.You are not required to choose
are administered by United Behavioral Health             a primary care physician, and you do not need
(UBH). See page 79.                                      a referral to see a specialist.




                                                                                                              1
Welcome to the UniCare State Indemnity Plan/Community Choice


Hospital Services                                      You’ll save on out-of-pocket costs for physician office
With the Community Choice Plan, the amount you         visits when you use Tier 1 or Tier 2 physicians in
pay in copays and coinsurance for inpatient and        Massachusetts – those who have demonstrated
outpatient hospital care depends on which hospital     quality and/or cost-efficiency in their practices. For
you use. You have the lowest costs when:               more information on physician tiering, see page 13
                                                       in the “Your Costs” section of this Handbook, or
1. You use hospitals on the Community Choice
                                                       visit www.unicarestateplan.com > “Members” >
   hospital listing (see Appendix C).
                                                       “Forms and Documents.”
2. You have one of the Complex Procedures
                                                       : To find out which tier your physician is in, log
   performed at one of the Designated Hospitals
                                                       onto the Plan’s website: www.unicarestateplan.com
   listed in Appendix D.
                                                       > “Find a Provider” > “Physician Tier Listing.”
3. You receive a transplant at any of the Quality      You can also check the printed Provider Listing, or
   Centers and Designated Hospitals for                call the Andover Service Center at (800) 442-9300
   Transplants. Call a Member Care Specialist          for assistance.
   at (800) 442-9300 for more information.
                                                       •	 When You Travel: When you travel outside of
4. You receive care at any acute                          Massachusetts, you have access to UniCare Travel
   rehabilitation facility.                               Access providers for urgent care. (For out-of-state
                                                          mental health/substance abuse providers, you
For all other inpatient and outpatient care, you pay
                                                          have access to the United Behavioral Health
higher copays and coinsurance. For details, see
                                                          network instead of the UniCare network. See page
“Copayments” and “Coinsurance” in the “Your
                                                          79 for more information). Our Travel Access
Costs” section.
                                                          providers agree not to balance bill you for charges
For help with your hospital and physician choices,        above the Plan’s allowed amount. Student
contact a Member Care Specialist at the Andover           dependents who attend school full time in states
Service Center at (800) 442-9300. Member Care             other than Massachusetts also have access to
Specialists can assist you in finding physicians who      UniCare Travel Access providers. It is important
are affiliated with Community Choice hospitals,           for you and your dependent(s) to use these
where you will have lower copays for inpatient and        providers while outside Massachusetts so you
outpatient care. This individual will work closely        won’t be balance billed for your care.
with you to help you manage your health care
                                                         : To locate a Travel Access provider when you
choices and direct you to appropriate health
                                                         travel, log onto www.unicarestateplan.com > “Find
resources. See page 4 for more information about
                                                         a Provider” > “Out-of-State Network Providers”
the various ways our Member Care Specialists
                                                         and follow the directions. Or call Customer
can assist you.
                                                         Service at (800) 442-9300 for assistance.

How to Get the Highest Level of                        •	 The Andover Service Center must be notified of
                                                          all hospital admissions and certain outpatient
Benefits from Your Medical Plan                           services by calling (800) 442-9300. The telephone
Please read the following information carefully           symbol ( you see throughout this Handbook lets
to ensure that you get the maximum benefit for            you know that, to obtain the maximum benefit,
medically necessary services.                             you must call the Andover Service Center within




2
Welcome to the UniCare State Indemnity Plan/Community Choice


 the required time frame. Failure to do so may         The computer symbol : that you see throughout
 result in your benefit being reduced by up to         this Handbook indicates that information on the
 $500. However, you do not need to call the Plan       highlighted topic is available on the Plan’s website.
 if you are outside the continental United States      Our comprehensive Web resources give you the
 (the contiguous 48 states). Please refer to the       ability to:
 “Managed Care Program” section of this
 Handbook for specific notification requirements       •	 Develop healthier habits to improve your health
 and responsibilities. You’ll also find details           and well-being with our Wellness Tool Kit.
 regarding what information you need to provide           Participate in one of our online Lifestyle
 when you call the Plan to give notification of           Improvement Programs, such as weight
 an admission or service.                                 management, exercise or stress management. Use
                                                          our convenient health trackers to chart your health
•	 Use Community Choice hospitals for hospital            measures over time, such as cholesterol, weight
   care. For a comparison of benefits when you            and blood pressure. Take the health assessment
   use Community Choice hospitals versus non-             to find out how healthy you are. And get reliable,
   Community Choice hospitals, refer to the “Benefit      up-to-date health information to keep you in the
   Highlights” section. Also see “About Your Medical      know. These are just a few of the online health
   Plan” on page 1.                                       resources you’ll find in the Wellness Tool Kit.
•	 To receive the maximum benefit, you should          •	 Get information on initiatives and resources that
   use UniCare’s preferred vendors for the                promote health care quality. Learn about efforts
   following services:                                    to help hospitals reduce preventable medical
 − Durable medical equipment                              errors. You’ll also find resources to help you select
 − Medical/diabetic supplies                              a hospital based on a comparison of quality and
 − Home health care                                       cost, and more.
 − Home infusion therapy                               •	 Locate providers, including Community Choice
 For a list of the Plan’s current preferred vendors,      hospitals, UniCare out-of-state network providers
 see Appendix J.                                          and preferred vendors. You can also check our
                                                          Provider Listing to see which tier your physician
•	 Carry your UniCare State Indemnity Plan ID card        is in.
   with you at all times and always show it when
   you get medical care. This enables your provider    •	 Get convenient, secure access to information
   to confirm your eligibility for Plan benefits.         about your claims.
                                                       •	 Check out the Plan’s discounts on health-related
Online Access to Medical                                  products and services available through the
Information and Plan Resources                            Special Offers Program.
at www.unicarestateplan.com                            •	 Email the Plan or order Plan materials, such as ID
                                                          cards and Handbooks.
For your convenience, you can access a broad range
of Plan-related and general health care information,   •	 View Plan documents, including your Handbook
as well as helpful tools on the Plan’s website:           and other Plan information.
www.unicarestateplan.com.




                                                                                                               3
MedCall 24/7 Nurse Information Line                     call MedCall toll free at (800) 424-8814. You
                                                        will need to provide the following Plan-specific
The Plan’s MedCall® 24/7 Nurse Information Line         code: 1002.
provides around-the-clock, toll-free access to
registered nurses who can answer your questions         By calling the above number, you can also access
about procedures or symptoms that you would like        MedCall’s library of more than 400 audio tapes to
to discuss. Nurses can provide information about        get automated information over the phone on many
appropriate care settings and help you prepare          health-related topics.
for a doctor’s visit. They can also discuss your        : To view the list of available audio tapes, log onto
medications and any potential side effects. MedCall     www.unicarestateplan.com > “Quick Links” >
also serves as a referral source for local, state and   “Health and Wellness” > “MedCall.”
national self-help agencies. To speak with a nurse,




    Important Plan Information
Overview                                                component of the Plan. Member Care Specialists are
                                                        available Monday through Thursday from 7:30 a.m.
This section gives you important information about      to 6:00 p.m. and Friday from 7:30 a.m. to 5:00 p.m.
the Community Choice Plan, including:                   to answer questions you and your family may have
•	 The Andover Service Center and how its staff can     about your medical coverage.
   help you                                             : You can also access claims information 24 hours
•	 The process for ordering new identification cards    a day, seven days a week from our automated
   when needed                                          telephone line, or from the Plan’s website:
                                                        www.unicarestateplan.com > “Quick Links” >
•	 How to access a language interpreter when            “Check Your Claims.”
   speaking with a Member Care Specialist at the
   Andover Service Center                               When you call the Andover Service Center, you will
                                                        speak with a Member Care Specialist or a patient
•	 Contact information when you have questions          advocate, depending on the nature of your call.
   about your medical plan, your prescription drug
   plan or your mental health, substance abuse and      Member Care Specialists: Here to Help You
   Enrollee Assistance Programs                         Member Care Specialists are the Plan’s specially-
                                                        trained Customer Service representatives who you
•	 The GIC’s Notice of Privacy Practices                can contact for assistance with your health plan
                                                        questions and concerns. They do not act as
The Andover Service Center                              gatekeepers; they simply help you manage your
The Andover Service Center is where UniCare             health care choices and direct you to appropriate
administers services; processes claims; and provides    health resources.
customer service, utilization management and
medical case management for the medical




4
Important Plan Information


Member Care Specialists can:                             Patient Advocates
•	 Help you choose an appropriate hospital or            Patient advocates are registered nurses who can
   preferred vendor for the care you need so you         help you coordinate your health care needs with
   receive the highest level of benefits                 the benefits available under the Plan. The patient
                                                         advocate can:
•	 Assist you in finding physicians who are affiliated
   with Community Choice hospitals, where you            •	 Provide information about the Managed Care
   will have lower copays and no coinsurance for            Program, including Utilization Management,
   inpatient and outpatient care                            Medical Case Management, and Quality Centers
                                                            and Designated Hospitals for Transplants
•	 Put you in touch with the Plan’s nurse
   health educators                                      •	 Answer questions about the Plan’s coverage for
                                                            hospital stays and certain outpatient benefits
•	 Provide you with information about supportive
   health care programs offered by the Plan              •	 Speak with you and your physician about covered
                                                            and non-covered services to help you obtain care
•	 Answer questions about the Plan’s
                                                            and coverage in the most appropriate health care
   notification requirements
                                                            setting and let you know what services are covered
•	 Provide answers to general benefits and
                                                         •	 Assist you with optimizing benefits for covered
   coverage questions
                                                            services after you are discharged from the hospital
Connecting to Support: As indicated above, Member
Care Specialists can also help members who would         Your Identification Card
benefit from additional assistance. Based upon your
health care needs, the Member Care Specialist may        When you are enrolled in the Plan, you will receive
direct you to:                                           an identification (ID) card. Be sure to present your
                                                         ID card when you seek medical care. Your card
•	 Health improvement programs where registered          contains useful information about your benefits and
   nurses help you work with your doctor to actively     important telephone numbers you and your doctor
   manage chronic conditions such as congestive          may need.
   heart failure, diabetes and asthma
                                                         : If you lose your ID card or need additional cards,
•	 MedCall, a toll-free telephone line that connects     you can order new cards from the Plan’s website at
   you to a registered nurse or an audiotape library     www.unicarestateplan.com. You can also call the
   available 24 hours a day, seven days a week           Andover Service Center at (800) 442-9300.
•	 Utilization management, a review process for
   surgeries and hospitalizations                        Interpreting and Translating Services
•	 Case management, where registered nurses assist       If you need a language interpreter when you contact
   you and your family when you are faced with           the Andover Service Center, a Member Care
   a serious medical problem                             Specialist will access a language line and connect
                                                         you with an interpreter who will translate your
                                                         conversation with the Member Care Specialist.
                                                         If you are deaf or hard of hearing and have a TDD
                                                         machine, you can contact the Plan by calling its
                                                         telecommunications device for the deaf (TDD) line
                                                         at (800) 322-9161 or (978) 474-5163.




                                                                                                              5
              Notice of Privacy Practices                              For information about your prescription drug plan:
 Your Costs
Your Claims




              This notice describes how medical information            CVS Caremark
              about you may be used and disclosed and how you          (877) 876-7214 (toll free)
              can get access to this information. The GIC keeps        TDD: (800) 238-0756
              the health and financial information of current and      www.caremark.com
              former members private, as required by law. This         For information about your mental health
              notice also explains your rights as well as the GIC’s    and substance abuse benefits and the Enrollee
              legal duties and privacy practices. The GIC’s policies   Assistance Program:
              comply with the Health Insurance Portability and
              Accountability Act (HIPAA), the federal standard         United Behavioral Health
              for the protection of personal health information.       (888) 610-9039 (toll free)
                                                                       TDD: (800) 842-9489
              The GIC’s Notice of Privacy Practices is contained       www.liveandworkwell.com
              in Appendix A at the back of this Handbook.              (access code: 10910)
              Please read this notice carefully.

              Important Contact Information
              If you have questions, please contact the following:
              For information about your medical benefits:
              UniCare State Indemnity Plan
              P.O. Box 9016
              Andover, MA 01810-0916
              (800) 442-9300 (toll free)
              TDD: (800) 322-9161
              www.unicarestateplan.com




                  Your Costs
              Overview                                                 Calendar Year Deductible
              This section describes the costs that you may            The calendar year deductible is a fixed dollar
              be responsible for paying in connection with             amount you pay for certain services before the Plan
              services covered by the Plan. These costs include        begins paying benefits for you or for your covered
              copayments, deductibles and coinsurance. This            dependent(s). The calendar year deductible amounts
              section also explains how the Plan reimburses            you must satisfy are shown in the chart below. In
              health care providers, and provides information          addition to meeting the calendar year deductible,
              about physician tiering and using non-                   you are also responsible for copays and coinsurance
              Massachusetts providers.                                 amounts, where applicable.




              6
Your Costs


The federal Mental Health Parity law mandates            The calendar year deductible applies to most of the




                                                                                                                   Your Claims
                                                                                                                   Your Costs
that the deductible for medical benefits and the         medical services you receive. Check the Summary
deductible for out-of-network mental health/             of Covered Services charts in “Benefit Highlights”
substance abuse benefits be shared (treated as           to see which services the calendar year deductible
one deductible).                                         applies to.

 Calendar Year Deductibles
                                                      All Medical Providers and
                                       Out-of-Network Mental Health/Substance Abuse Providers
 Individual Calendar             $250 per individual per calendar year for medical and mental health/
 Year Deductible                 substance abuse services
 Family Calendar                 $750 per family per calendar year for medical and mental health/
 Year Deductible                 substance abuse services
                                 The deductible for any individual family member is limited to $250


Individual Calendar Year Deductible                      Family Calendar Year Deductible
The $250 individual calendar year deductible is the      The family calendar year deductible is the maximum
amount you must pay each year before the Plan            amount your family could pay each year before the
begins to pay for many medical services and out-of-      Plan begins to pay for many services from medical
network mental health/substance abuse services.          providers or out-of-network mental health/substance
                                                         abuse providers. The maximum any one family
Example – In January, you get mental health services
                                                         member must satisfy is $250, until the family as a
from an out-of-network provider and pay $150
                                                         whole reaches the $750 maximum.
toward your deductible. You now still owe $100
toward your deductible. In February, you go to a         Example – In January, you and your two children go
provider for medical care. If this second bill is more   to providers for medical care. All three of you pay
than $100, you pay $100 – the rest of your deductible    $200 deductibles, for a total of $600 toward the
– and the Plan pays the covered amount of the            family calendar year deductible. In February, your
remaining charges. However, if this second bill is       spouse goes to an out-of-network mental health
less than $100 (the deductible balance you still owe),   provider and pays a $150 deductible. Even though
then the balance you still owe will be taken the next    no single family member has met the $250
time you go to a medical or out-of-network mental        individual deductible, the family deductible of $750
health/substance abuse provider.                         has been met. Therefore, no additional calendar
                                                         year deductible will apply to your family for the rest
Once you have paid the $250 calendar year
                                                         of the calendar year.
deductible to any combination of medical providers
and out-of-network mental health/substance abuse         Deductible Carryover
providers, you will not have to pay it again for         Any deductible amounts you pay for services
the rest of the calendar year.                           rendered during the last three (3) months of a
                                                         calendar year will apply toward the deductible
The Plan determines the providers to whom you
                                                         requirement for the next year, provided that
owe the deductible based on the order in which
                                                         you had continuous coverage under the Plan
your claims are submitted. You will receive
                                                         since the time the charges in the prior year
an Explanation of Benefits (EOB) that will list
                                                         were incurred.
the provider(s) to whom you owe the deductible
amounts for any services you received.


                                                                                                               7
              Your Costs


              Copayments                                                  within 30 days following a hospital discharge,
 Your Costs
Your Claims



                                                                          within the same calendar year (even if the
              A copayment (“copay”) is a fixed dollar amount you          admissions occur in different calendar year
              pay to a provider at the time of service. Copay             quarters). This copay does not apply toward the
              amounts vary depending on the type of provider,             calendar year deductible.
              the type of service you receive, the tier level of the
              physician, and whether you use a Community                  Example 1 – If you are admitted in January to any
              Choice hospital or a non-Community Choice                   of the hospitals specified in items 1-5 in the
              hospital. Copays are always deducted before the             inpatient hospital care copay chart on page 10, and
              individual calendar year deductible is applied (where       stay overnight, you will be responsible for paying
              applicable). Copays do not count toward satisfying          the inpatient hospital copay. If you are re-admitted
              the annual calendar year deductible, coinsurance            to one of these hospitals in March, you will not be
              amounts or out-of-pocket maximums. See the                  responsible for another copay, because March is
              copay chart on pages 10-11 for copays for each type         in the same calendar year quarter as January.
              of service.                                                 However, if you are re-admitted to one of these
                                                                          hospitals in May, you will incur another inpatient
              Example 1 – If you go to a physician’s office, you          hospital copay.
              may be responsible for paying an office visit copay.
              Although you usually pay the copay at the time              Example 2 – If you are admitted to one of these
              of the visit, you can also wait until the provider          hospitals at the end of March and then re-admitted
              bills you.                                                  in April (within 30 days of your March discharge),
                                                                          you will not be responsible for another inpatient
              Example 2 – You will owe the emergency room                 hospital copay. But if you are re-admitted to one
              copay every time you go to the emergency room.              of these hospitals in May (more than 30 days from
              This copay is waived if you are admitted to the             your March discharge), you will incur another
              hospital. However, if you are admitted to the               inpatient hospital copay.
              hospital, the inpatient hospital copay applies.
                                                                          Example 3 – If you are admitted to one of these
              Inpatient Hospital Copays                                   hospitals at the end of December and then are
              You pay different copays for inpatient hospital             re-admitted in the beginning of January, you will
              services, depending on where you receive care,              be responsible for another inpatient hospital copay
              as follows:                                                 because the admissions were not in the same
              •	 When you use a Community Choice hospital or              calendar year (even though the two admissions
                 one of the hospitals under the circumstances             occur within 30 days of each other).
                 specified in items 2-5 in the inpatient hospital care   •	 When you use a hospital other than those
                 copay chart on page 10, the inpatient hospital             specified in items 1-5 in the chart on page 10,
                 copay applies on a per-person, per-calendar-year-          the inpatient hospital copay applies on a per-
                 quarter basis. Each time you or a covered                  person, per-admission basis. When you or a
                 dependent is admitted to a hospital, you are               covered dependent is admitted to a hospital other
                 responsible for this copay. However, once a                than those listed in items 1-5 on page 10, you
                 covered person pays this copay in any single               are responsible for this copay. (You are also
                 calendar year quarter, he or she will not have to          responsible for coinsurance; see page 12.)
                 pay the copay again during that same calendar
                 year quarter. In addition, the inpatient hospital
                 copay is waived for re-admissions that occur




              8
Your Costs


Outpatient Surgery Copays                                Note: When you have outpatient surgery at




                                                                                                                     Your Claims
                                                                                                                     Your Costs
You pay different copays for outpatient surgery at a     a freestanding ambulatory surgical center or at
hospital, depending on where you receive care, as        a physician’s office, you do not have to pay the
shown in the outpatient care copay chart on page 11.     outpatient surgery copay.
•	 When you use a Community Choice hospital –            Copays for Medical Services
   The outpatient surgery copay is a per-person,         The chart that starts on page 10 lists the copays you
   per-calendar-year-quarter copay. Each time you or     are responsible for with certain types of medical
   a covered dependent has surgery at a Community        services. As described in “Physician Tiering” on
   Choice hospital, you are responsible for paying       page 13, Massachusetts physicians are assigned to
   this copay. However, once a covered person pays       one of three tiers. The copay chart lists the copays
   the outpatient surgery quarterly copay in any         for each tier. (Please note that you are not required
   calendar year quarter, he or she will not have to     to select a primary care physician.)
   pay this copay again during that same calendar
                                                         You can also use the following providers at a Tier 2
   year quarter. This copay does not apply toward
                                                         level copay:
   the calendar year deductible.
                                                         •	 All non-Massachusetts physicians
  Example – If you have outpatient surgery in
  January at a Community Choice hospital, you will       •	 Physicians listed in the Provider Listing with the
  be responsible for paying the outpatient surgery          indication that they do not have sufficient data
  copay at Community Choice hospitals on the                available to allow us to score them – such as those
  hospital charges. If you have another surgery in          physicians who are new to practice
  March, you will not have to pay another outpatient
                                                         •	 Nurse practitioners and physician assistants
  surgery copay, because March is in the same
  calendar year quarter as January. However, if you      Note: The names of the tiers have been assigned
  have outpatient surgery at a hospital in May, you      by the GIC for use uniformly across all of its
  will incur another outpatient surgery copay.           health plans.
•	 When you use a non-Community Choice hospital –
   The outpatient surgery copay is a per-person, per
   occurrence copay. Each time you or a covered
   dependent has surgery at one of these hospitals,
   you are responsible for paying this copay. (You are
   also responsible for coinsurance; see page 12.)




                                                                                                                 9
              Your Costs


              Copays for Medical Services
 Your Costs
Your Claims




               ( Inpatient Hospital Care
               Where You Receive Hospital Care                                                       Inpatient Hospital Copay
               You pay the lowest copays when:
               1. You use hospitals on the Community Choice Hospital Listing                         $250 per calendar quarter.
                  (see Appendix C)                                                                   The inpatient hospital copay
                                                                                                     is waived for re-admissions
                                                        OR
                                                                                                     that occur within 30 days
               You use non-Community Choice hospitals in the                                         of a hospital discharge,
               following situations:                                                                 within the same calendar year.
               2. You have one of the Complex Procedures performed at one
                  of the Designated Hospitals listed in Appendix D
               3. You get admitted to any hospital through the emergency room
               4. You receive care at any acute rehabilitation facility, or
               5. You receive a transplant at any of the Quality Centers and
                  Designated Hospitals for Transplants1
               You pay higher copays when:                                                           $750 per admission.
                                                                                                     The inpatient hospital copay
               You use any hospital other than those specified above2
                                                                                                     is waived for re-admissions
                                                                                                     that occur within 30 days
                                                                                                     of a hospital discharge, within
                                                                                                     the same calendar year.




              ( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
              Care Program” section for specific notification requirements and responsibilities.
              1 For more information regarding Quality Centers and Designated Hospitals for Transplants, call and speak to a UniCare medical
              case manager at (800) 442-9300.
              2 When you use these hospitals, you are also responsible for 20% coinsurance up to a $5,000 maximum. See page 12.


              10
Your Costs


Copays for Medical Services (continued)




                                                                                                                                           Your Claims
                                                                                                                                           Your Costs
 Outpatient Care
                                              Copay at a                                    Copay at
 Type of Medical Visit                        Community Choice Hospital                     Other Hospitals
 ( Outpatient Surgery                         $110 per quarter                              $250 per occurrence1
 Emergency Room                               $100 (waived if admitted)                     $100 (waived if admitted)
 ( Outpatient High-Tech                       $100 per scan; maximum of one                 $200 per scan; maximum of one
 Imaging (such as MRIs, CT                    copay per day                                 copay per day
 scans and PET scans) at hospital
 and non-hospital locations
 All other outpatient radiology               None                                          $50
 services at a hospital
 Outpatient Diagnostic                        None                                          $50
 Laboratory Services at
 a hospital
                                                                                At Any Provider
 Physician Office Visits
 Tier 1*** (excellent):
   Primary care physician2                                                              $15
   Specialty care physician                                                             $25
 Tier 2** (good):
   Primary care physician2                                                              $30
   Specialty care physician                                                             $30
 Tier 3* (standard):
   Primary care physician2                                                              $35
   Specialty care physician                                                             $45
 Services provided by                                                                   $30
 Nurse Practitioners
 ( Physical Therapy and                                                                 $15
 ( Occupational Therapy
 ( Chiropractic Care                                                                    $15
 Routine Eye Examinations:
   With an Optometrist                                                          $30
   With an Ophthalmologist                              See specialty care physician office visit copays above
 Licensed Retail Medical Clinics                                                $20
 at Retail Pharmacies

( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
Care Program” section for specific notification requirements and responsibilities.
1 When you use these hospitals, you are also responsible for 20% coinsurance up to a $5,000 maximum. See page 12.
2 Primary care physicians are pediatricians, and physicians specializing in family medicine, general medicine and/or internal
medicine. Some primary care physicians may also be specialty care physicians and, if so, may be considered to be specialists in the
determination of their tier and copay assignments. This means you will pay the office visit copay for the type of practice the physician
has been designated to, regardless of whether you see the physician for a primary care or specialty care visit.



                                                                                                                                     11
              Your Costs


              Coinsurance                                              Allowed Amount
 Your Costs
Your Claims




              Coinsurance is the percentage of the allowed             The allowed amount is the amount UniCare
              amount that you must pay for covered services            determines to be within the range of payments most
              after any applicable copay or deductible is satisfied.   often made to similar providers for the same service
              For example, if the Plan pays 80% of the allowed         or supply. These allowed amounts are expressed as
              amount for certain services, you are responsible         maximum fees in fee schedules, maximum daily
              for paying the remaining 20%.                            rates, flat amounts or discounts from charges.
              When you have inpatient hospital care or outpatient      The Plan has established allowed amounts for most
              surgery at a non-Community Choice hospital,              services from providers. This allowed amount may
              you are responsible for 20% coinsurance (see the         not be the same as the provider’s actual charge.
              “Benefit Highlights” section).
              In addition, you may be responsible for the              Charges above the Allowed Amount
              difference between the allowed amount and the            In some cases, a provider may bill you for charges
              provider’s charge (a balance bill) for services          above the allowed amount; this is called a balance
              received from providers outside of Massachusetts         bill. The Plan will not consider balance bills
              if you do not use UniCare Travel Access providers.       for payment.
              To learn about these providers, see the information
              about non-Massachusetts providers under                  Massachusetts Providers
              “Charges above the Allowed Amount” below.                Under Massachusetts General Law, Chapter 32A:
                                                                       Section 20, providers who render services in
                                                                       Massachusetts are prohibited from billing you
              Out-of-Pocket Maximum
                                                                       for amounts above the Plan’s allowed amounts.
              To protect you from large medical expenses, the          If you receive such a bill from a Massachusetts
              Plan limits the amount of coinsurance you pay each       provider, contact the Andover Service Center
              year for certain covered services. Once you reach        to help you resolve this issue.
              the out-of-pocket maximum, the Plan pays 100%
              of the allowed amount for the designated covered         Non-Massachusetts Providers
              services for the rest of the calendar year. This         Non-Massachusetts providers may balance bill you
              out-of-pocket maximum applies to each covered            for the difference between the payments made
              person, as follows:                                      by the Plan, based on the Plan’s allowed amount,
                                                                       and the full amount the provider charged. The
               Community Choice            Non-Community               charges above the Plan’s allowed amounts will not
               Hospital                    Choice Hospital             be considered for payment by the Plan. To avoid
                                                                       these charges:
               $750                        $5,000
                                                                       •	 When You Travel: When you travel outside
              When you use Community Choice hospitals, most               Massachusetts, you have access to UniCare Travel
              services are covered at 100%, so the only medical           Access providers for urgent care, except for mental
              costs that apply toward your out-of-pocket maximum          health/substance abuse providers. (See the note
              are home health care, prostheses, braces and other          below regarding mental health/substance abuse
              covered medical services such as allergy serum.             providers.) Travel Access providers agree not to
                                                                          balance bill you for charges above the Plan’s
              Deductibles, copayments, certain coinsurance
                                                                          allowed amount. Student dependents who attend
              amounts, any amounts paid above the allowed
                                                                          school full time in states other than Massachusetts
              amount, and amounts for non-covered services
                                                                          also have access to UniCare Travel Access
              do not apply toward the out-of-pocket maximum.



              12
Your Costs


  providers. It is important for your dependent(s) to    (GIC) Clinical Performance Improvement (CPI)




                                                                                                                  Your Claims
                                                                                                                  Your Costs
  use these providers while outside Massachusetts        Initiative includes a physician tiering program.
  so you won’t be balance billed for their care. When    Under this program, Massachusetts physicians are
  you use Travel Access providers, please show your      assigned to tiers based on an evaluation of how
  UniCare State Indemnity Plan ID card.                  they performed on various quality and/or cost-
                                                         efficiency measures. Based on a comparison of
 :
 	
	 To locate UniCare Travel Access providers,
                                                         their scores with their peers in the same specialties
  log onto www.unicarestateplan.com > “Find a
                                                         on these efficiency measures, as well as whether
  Provider” > “Out-of-State Network Providers” and
                                                         the physician met certain quality benchmarks,
  follow the directions. The provider finder will
                                                         individual physicians are assigned to one of three
  help you identify UniCare Travel Access providers,
                                                         tiers, as described below. The names of the tiers
  who will not balance bill you for your care.
                                                         have been assigned by the GIC for use uniformly
Note: If you need mental health/substance abuse          across all of its participating health plans.
treatment or the Enrollee Assistance Program
                                                         For most specialties, physicians have been tiered
(EAP), you must contact United Behavioral Health
                                                         based on both their quality and cost-efficiency
(UBH), the administrator for these services. You
                                                         scores. However, there are some specialties
will be subject to balance billing if you use a mental
                                                         (excluding primary care) where sufficient quality
health/substance abuse provider that is not in the
                                                         measures are not readily available to develop an
UBH network. (For more information, please see
                                                         adequate evaluation of quality. Therefore, we have
page 79.)
                                                         tiered some physicians on the basis of cost-efficiency
Preferred Vendors                                        scores only.
Preferred vendors, whether located within or outside
                                                         •	 Tier 1*** (Excellent) – Tier 1 physicians are
of Massachusetts, are contracted to accept the Plan’s
                                                            generally those who met or exceeded the quality
allowed amount. Therefore, they cannot balance
                                                            assessment threshold, established for all
bill you for any charges above the allowed amount
                                                            physicians, and ranked at the highest level of
determined by the Plan. See Appendix J for a list
                                                            cost efficiency, as compared to their peers. Tier 1
of preferred vendors.
                                                            is designed to acknowledge the high performance
                                                            of these physicians in terms of both quality and
Provider Reimbursement                                      cost-efficiency measures, as determined by the
The Plan reimburses providers on a fee-for-service          available data. (Some specialty physicians, for
basis. The Plan does not withhold portions of               whom quality data were insufficient to allow
benefit payments from providers, nor does it offer          for evaluation, were placed in Tier 1 solely on
incentive payments to providers related to                  the basis of their rank at the highest level of
controlling the utilization of services. Explanations       cost efficiency. These physicians are identified
of provider payments are detailed in your                   as such in the printed Provider Listing and
Explanations of Benefits (EOBs). Under the Plan,            the online Physician Tier Listing at
providers are not prohibited from discussing the            www.unicarestateplan.com.)
nature of their compensation with you.                   •	 Tier 2** (Good) – Tier 2 physicians are those who
                                                            have met or exceeded the quality assessment
Physician Tiering                                           threshold established for all physicians. They
To help you make more informed choices about                have also met the cost-efficiency performance
your health care options and to control your                standard, but did not achieve scores as high as
premium costs, the Group Insurance Commission’s             Tier 1 physicians.




                                                                                                             13
              •	 Tier 3* (Standard) – Tier 3 physicians are those       The methodology used in this tiering process relies
 Your Costs
Your Claims



                 who did not meet the quality assessment                on nationally accepted approaches to evaluating both
                 threshold established for all physicians, or           quality and cost efficiency, and uses claims data
                 they did not meet the cost-efficiency                  submitted by health care providers themselves.
                 performance standard.                                  The use of claims data has some limitations, and
                                                                        there are additional methods that you may wish to
              Note: For a variety of reasons, many physicians did
                                                                        use in evaluating the quality and cost efficiency of
              not have sufficient data available during the data
                                                                        providers. In making decisions about choosing
              collection period to allow us to assess their quality
                                                                        your providers, you should consider the potential
              and/or cost efficiency. In the Plan’s Provider Listing,
                                                                        limitations in the data as well as other factors that
              these physicians are placed in the category of Not
                                                                        correlate with the quality of care that you receive,
              Tiered/Insufficient Data (NT/ID). You can see these
                                                                        some of which may be subjective in nature, but
              physicians for a Tier 2 level copay.
                                                                        which are important to you.
              : You will find detailed explanations about
                                                                        How to Find Out Your Physician’s Tier Designation
              the assignment of doctors to tiers and about
                                                                        : To find out which tier your physician is in, log
              the methods used to determine the quality
                                                                        onto the Plan’s website: www.unicarestateplan.com >
              and cost efficiency scores of the physicians at
                                                                        “Find a Provider” > “Physician Tier Listing.”
              www.unicarestateplan.com > “Members” >
                                                                        You can also check the printed Provider Listing, or
              “Forms and Documents.” You can also call the
                                                                        call the Andover Service Center at (800) 442-9300
              Andover Service Center at (800) 442-9300 to
                                                                        for assistance.
              request materials.




                Your Claims
              Overview                                                  •	 Diagnosis
                                                                        •	 Date of service
              This section provides information on how to submit        •	 Amount of charge
              a claim, how your benefits are covered when you have      •	 Name, address and type of provider
              coverage under more than one health plan, how             •	 Provider tax ID number, if known
              to view your claims online, the Plan’s claim review       •	 Name of enrollee
              process, your appeal rights under the Plan, and           •	 Enrollee’s ID number
              other important information relating to your claims.      •	 Name of patient
                                                                        •	 Description of each service or purchase
              How to Submit a Claim                                     •	 Information on any other group health insurance
                                                                           plan(s) under which you may be covered
              To receive benefits from the Plan, a claim must be
                                                                        •	 Accident information, if applicable
              filed for each service. Most hospitals, physicians or
                                                                        •	 Proof of payment, if applicable
              other health care providers will submit claims for
              you. If your provider files claims on your behalf, the    If the proof of payment you receive from a provider
              provider will be paid directly. If you submit your        contains information in a foreign language,
              own claim, you must include written proof of the          please provide the Plan with a translation of this
              claim that includes:                                      information, if possible.




              14
Your Claims


The Plan’s claim form may be used to submit              •	 Have you been charged for more services than




                                                                                                                     Your Claims
                                                                                                                     Your Costs
written proof of a claim. For your convenience,             you received?
a claim form can be found in Appendix E of this
                                                         •	 Did you receive the laboratory services described
Handbook. : You can also print or request
                                                            on the bill?
this form from www.unicarestateplan.com >
“Members” > “Forms and Documents.”                       •	 Does the room charge reflect the correct number
                                                            of days?
Original bills or paid receipts from providers will
also be accepted as long as the information              •	 Were you charged for the correct type of room?
described above is included.
                                                         When Errors Are Detected
Filing Deadline                                          If you find an error, contact the provider or the
Written proof of a claim must be submitted to the        provider’s billing office and report the exact charges
Plan within two years from the date of service.          you are questioning. Request an explanation of any
Claims submitted after two years will be accepted        discrepancies and ask for a revised itemized bill
for review if it is shown that the person submitting     showing any adjustments.
the claim was mentally or physically incapable of
                                                         How to Receive Your Share of the Savings
providing written proof of the claim in the required
                                                         To receive your share of the savings, you must send
time frame.
                                                         copies of both the original and revised bill(s) to the
                                                         Plan along with the completed Bill Checker form.
Checking Your Claims for                                 For your convenience, a Bill Checker form can be
Billing Accuracy                                         found in Appendix F of this Handbook.
Bill Checker Program                                     : You can also request this form from
The goal of the Bill Checker Program is to detect        www.unicarestateplan.com. Be sure to include the
overpayments that are the result of billing errors       enrollee’s name and identification number on the
that only you, as the patient, may recognize. Just       Bill Checker form. The Plan will review the two
as you might do with your utility bills, the Plan        bills and, if a billing error is confirmed, you will
encourages you to review all of your bills for           receive 25% of any savings that the Plan realizes.
accuracy. In those instances where you do detect         All reimbursements are subject to applicable state
a billing error and you are able to obtain a corrected   and federal income taxes.
bill from your provider, you will share in any
actual savings realized by the Plan.                     Provider Bills Eligible under the Program
                                                         All bills for which UniCare provides the primary
What You Need to Do                                      benefits are eligible under the Bill Checker
You must request that the provider send you an           Program. Bill Checker is not applicable to members
itemized bill for the services you received. As soon     who have Medicare as their primary coverage.
as possible, review this bill for any charges that       This program may not apply to certain inpatient
indicate treatment, services or supplies that you        bills paid under the Diagnosis Related Group
did not receive. Check items such as:                    (DRG) methodology. Bills for prescription drugs
                                                         and mental health/substance abuse services
•	 Did you receive the therapy described on the bill?
                                                         are excluded.
•	 Did you receive X-rays as indicated on your bill?
•	 Are there duplicate charges on the same bill?




                                                                                                                15
              Your Claims


              Claims Review Process                                     Claims Inquiry
 Your Costs
Your Claims




              The Plan routinely reviews submitted claims to            If you have questions about your claims, you can
              evaluate the accuracy of billing information about        contact the Andover Service Center in one of the
              services performed. The Plan may request written          following ways to request a review of your claim:
              documentation such as operative notes, procedure
                                                                        •	 Call us at (800) 442-9300.
              notes, office notes, pathology reports and X-ray
              reports from your provider. In cases of suspected         •	 : Email us from www.unicarestateplan.com >
              claim abuse or fraud, the Plan may require that              “Contact Us.”
              the person whose disease, injury or pregnancy is
                                                                        •	 Write to the UniCare State Indemnity Plan,
              the basis of the claim be examined by a physician
                                                                           Claims Department, P.O. Box 9016, Andover, MA
              chosen by the Plan. This examination must be
                                                                           01810-0916.
              approved by the Executive Director of the GIC
              and will be performed at no expense to you.               If you have additional information, please include it
                                                                        with your letter. You will be notified of the result of
              Restrictions on Legal Action                              the investigation and of the final determination.

              No legal action or suit to recover benefits for charges   24-Hour Access to Claims Information
              incurred while covered under the Plan may be              You can also check the status of your claims
              started before 60 days after written proof of a claim     24 hours a day, seven days a week in the following
              has been furnished. Further, no such action or suit       two ways:
              may be brought more than three years after the time
                                                                        1. Call us at (800) 442-9300 and select the option
              such proof has been furnished. If either time limit
                                                                           to access our automated information line.
              is less than permitted by state law in the state you
              lived in when the alleged loss occurred, the limit is     2.   : Log onto www.unicarestateplan.com > “Quick
              extended to be consistent with that state law.                 Links” > “Check Your Claims.” Register by
                                                                             creating a user ID and password to protect the
              Right of Reimbursement                                         privacy of your information. Dependents age 18
                                                                             or older can access their individual claims
              The Plan will have a lien on any recovery made by              information by establishing their own user IDs
              you or your dependent(s) covered under this Plan               and passwords.
              for an injury or disease to the extent you or your
              dependent(s) has received benefits for such injury
                                                                        Coordination of Benefits (COB)
              or disease from the Plan. That lien applies to any
              recovery made by you or your dependent(s) from            You and your dependent(s) may be entitled to
              any person or organization that was responsible           receive benefits from more than one plan. For
              for causing such injury or disease, or from their         instance, you may be covered as a dependent under
              insurers. Neither you nor your dependent(s) will be       your spouse’s plan in addition to coverage under
              required to reimburse the Plan for more than the          your own plan, or your child may be covered under
              amount you or your dependent(s) recover for such          both plans. When you or your dependent(s) are
              injury or disease.                                        covered by two or more plans, one plan is identified
                                                                        as the primary plan for coordination of benefits
              You or your dependent(s) must execute and deliver
                                                                        (COB) and determining the order of payment. Any
              such documents as may be required, and do
                                                                        other plan is then the secondary plan.
              whatever is necessary to help the Plan in its
              attempts to recover benefits it paid on behalf of
              you or your dependent(s).



              16
Your Claims


If the UniCare State Indemnity Plan is the primary        liability insurance. This does not include a state




                                                                                                                    Your Claims
                                                                                                                    Your Costs
plan, benefit payments will be made in accordance         plan under Medicaid or any plan when, by law,
with the benefits payable under the Plan without          its benefits are in excess of those of any
taking the other plan’s benefits into consideration.      private insurance program or other non-
A secondary plan may reduce its benefits if               governmental program.
payments were paid by the UniCare State Indemnity
                                                         •	 Automobile no-fault coverage
Plan. If another plan is primary, benefit payments
under the UniCare State Indemnity Plan are               The term “plan” does not include school-accident
determined in the following manner:                      type plans, or coverage that you purchased on
                                                         a non-group basis.
(a) The Plan determines its covered expenses –
    in other words, what the Plan would pay in           Determining the Order of Coverage
    the absence of other insurance; then                 The following are the rules by which the Plan and
                                                         most other plans determine order of payment – that
(b) The Plan subtracts the primary plan’s benefits
                                                         is, which plan is the primary plan and which plan
    from the covered expenses determined in (a)
                                                         is the secondary plan:
    above; and then
                                                         (a) The plan without a COB provision is primary.
(c) The Plan pays the difference, if any, between
    (a) and (b).                                         (b) The plan that covers the person as an employee,
                                                             member, or retiree (that is, other than a
The term “primary plan’s benefit” includes the
                                                             dependent) determines benefits before the plan
benefit that would have been paid had the claim
                                                             that covers the person as a dependent.
been filed with the other plan. For those plans
that provide benefits in the form of services, the       (c) The order of coverage for a dependent child
reasonable cash value of each service is considered          who is covered under both parents’ plans
as the charge and as the benefit payment. All COB            is determined as follows:
is determined on a calendar year basis for that part
                                                           1. The primary plan is the plan of the parent
of the year the person had coverage under the Plan.
                                                              whose birthday falls first in the calendar
For the purposes of COB, the term “plan” is defined           year; or
as any plan, including HMOs, that provides medical
                                                           2. If both parents have the same birthday, the
or dental care coverage including, but not limited to,
                                                              primary plan is the plan that has covered
the following:
                                                              a parent for the longest period of time.
•	 Group or blanket coverage
                                                           This is called the “birthday rule.” However,
•	 Group practice or other group prepayment                if the other plan has a rule based on the gender of
   coverage, including hospital or medical                 the parent, and, if the plans do not agree on the
   services coverage                                       order of coverage, the rules of the other plan will
                                                           determine the order.
•	 Labor-management trusteed plans
                                                         (d) The order of coverage for dependent children
•	 Union welfare plans
                                                             who are covered under more than one plan,
•	 Employer organization plans                               and whose parents are divorced or separated,
                                                             is determined in the following order:
•	 Employee benefit organization plans
                                                           1. First, the plan of the parent who is decreed
•	 Coverage under a governmental plan or coverage
                                                              by the court as financially responsible
   required or provided by law. This would include
                                                              for the health care expenses of the child
   any legally required, no-fault motor vehicle



                                                                                                               17
              Your Claims


                   2. Second, if there is no court decree, the plan of    in which case “payment made” means the
 Your Costs
Your Claims



                      the parent with custody of the child                reasonable cash value of the benefits provided
                                                                          in the form of services.
                   3. Third, if the parent with custody of the child is
                      remarried, the plan of the stepparent               Right of Recovery
                                                                          If the amount of payments made by the Plan is
                   4. Finally, the plan of the parent who does not
                                                                          more than it should have been under the COB
                      have custody of the child
                                                                          provision, the Plan may recover the excess from
              (e) The plan that covers a person as an active              one or more of the following:
                  employee (that is, someone who is not laid off
                                                                          •	 The persons it has paid or for whom it has paid
                  or retired) determines benefits for that person
                  and his or her dependent(s) before the plan that        •	 Insurance companies, or
                  covers that same person as a retiree.
                                                                          •	 Other organizations
                   This is called the “active before retiree” rule.
                                                                          The “amount of payments made” includes the
                   However, if the other plan’s rule is based on
                                                                          reasonable cash value of any benefits provided in
                   length of coverage, and, if the plans do not
                                                                          the form of services.
                   agree on the order of coverage, the rules of the
                   other plan will determine the order.
                                                                          Modification of COB Provisions for
              If none of the above rules can be applied when
              trying to determine the order of coverage, the plan
                                                                          Persons Enrolled in Medicare Parts A
              that has covered the person longer determines               and/or B
              benefits before the plan that has covered that same         The benefits for an enrollee or his/her dependent(s)
              person for the shorter period of time.                      covered under the UniCare State Indemnity Plan and
              Right to Receive and Release Information                    enrolled in Medicare will be determined as follows:
              In order to fulfill the terms of this COB provision or      (a) Expenses payable under Medicare will be
              any other provision of similar purpose:                         considered for payment only to the extent that
              •	 A claimant must provide the Plan with all                    they are covered under the Plan and/or Medicare.
                 necessary information.                                   (b) In calculating benefits for expenses incurred,
              •	 The Plan may obtain from or release information              the total amount of those expenses will first be
                 to any other person or entity.                               reduced by the amount of the actual Medicare
                                                                              benefits paid for those expenses, if any.
              Facility of Payment
              A payment made under another plan may include               (c) UniCare State Indemnity Plan benefits will
              an amount that should have been paid under the                  then be applied to any remaining balance
              UniCare State Indemnity Plan. If it does, the                   of those expenses.
              UniCare State Indemnity Plan may pay that amount            Special Provisions Applicable to Employees and
              to the organization that made the payment. That             Dependents Who Are 65 or Older and Eligible
              amount will be treated as if it were a benefit payable      for Medicare
              under the UniCare State Indemnity Plan. The                 An active employee or dependent of an active
              UniCare State Indemnity Plan will not have to pay           employee age 65 or over who is eligible for medical
              that amount again. The term “payment made”                  coverage under the Plan may continue medical
              includes providing benefits in the form of services,        coverage under the Plan regardless of their eligibility
                                                                          for, or participation in, Medicare.




              18
Your Claims


Medical Coverage Primary to Medicare                   During that 30-month period, the UniCare State




                                                                                                               Your Claims
                                                                                                               Your Costs
Coverage for the Disabled                              Indemnity Plan, for the purpose of the coordination
An employee or dependent covered under the Plan        of benefits (COB), is the primary payer and Medicare
who is under age 65 and who is entitled to Medicare    is the secondary payer. After the 30 months,
disability for reasons other than End Stage Renal      Medicare becomes the primary payer while the Plan
Disease (ESRD) may continue their medical coverage     becomes the secondary payer. At this point, you
under the Plan, regardless of their eligibility for,   must change health plans. Contact the GIC at:
or participation in, Medicare.                         Group Insurance Commission
Health Coverage Primary to Medicare Coverage           P.O. Box 8747
for Covered Persons Who Have End Stage                 Boston, MA 02114-8747
Renal Disease
For all covered persons with End Stage Renal           Appeal Rights
Disease (ESRD), coverage under the UniCare State       You have the right to appeal an adverse benefit
Indemnity Plan will be primary to Medicare during      determination made by the Plan within 180 days
the Medicare ESRD waiting period and the Medicare      of the notification of the determination. Please
ESRD coordination period.                              see Appendix H for instructions on how to file
“End Stage Renal Disease” means that stage of          an appeal.
kidney impairment that appears irreversible
and permanent and requires a regular course of         Request and Release of
dialysis or kidney transplant to maintain life.        Medical Information
“Medicare ESRD Waiting Period” is generally the        The GIC’s policies for releasing and requesting
first three months after starting dialysis. You are    medical information comply with the Health
not entitled to Medicare until after the three-month   Insurance Portability and Accountability Act
waiting period. This waiting period can be waived      (HIPAA). For more details, refer to the GIC’s
or shortened if a member participates in a             Notice of Privacy Practices in Appendix A of
self-dialysis training program or is scheduled         this Handbook.
for an early kidney transplant.
“Medicare ESRD Coordination Period” is 30 months
long and occurs after the ESRD waiting period.
The ESRD coordination period begins on the date
that Medicare became effective or would have
become effective on the basis of ESRD.




                                                                                                          19
                 Managed Care Program
               Overview                                                  providers to evaluate your clinical situation and the
                                                                         circumstances of your health care. In addition, your
               The Plan’s Managed Care Program includes the              physician will be offered the opportunity to speak
               following components:                                     with a physician advisor in the Managed Care
               1. Managed Care Notification Requirements                 Program to discuss the proposed treatment and/or
                                                                         the setting in which it will be provided.
               2. Utilization Management
                                                                         Managed Care Notification
Managed Care




               3. Medical Case Management
               4. Quality Centers and Designated Hospitals               Requirements
                  for Transplants                                        The review process is initiated when you, or
               The Managed Care Program determines the medical           someone on your behalf, notifies a Member Care
               necessity and appropriateness of certain health           Specialist that:
               care services by reviewing clinical information           •	 You or your dependent will be or has been
               (“clinical criteria”). This process, called Utilization      admitted to the hospital, or
               Management, a standard component of most
               health care plans, ensures that benefits are paid         •	 A provider has recommended one of the
               appropriately for services that meet the Plan’s              procedures or services noted on the Notification
               definition of medical necessity. Managed Care                Requirements chart on the following pages
               Program staff will inform you in advance regarding        : You will also find the Plan’s Notification
               what services will be covered. This Program helps         Requirements on the Plan’s website at
               control costs while preserving the ability of the         www.unicarestateplan.com > “Members” >
               Group Insurance Commission to offer the benefits          “Notification Requirements.” Select the link
               of an indemnity plan to members.                          for non-Medicare members.
               These clinical criteria are developed with input from     When you use any provider inside or outside
               actively practicing physicians in the Plan’s service      Massachusetts, you are responsible for meeting
               area, and are developed in accordance with the            the managed care notification requirements.
               standards adopted by the national accreditation
               organizations. They are updated at least three times      Important: If you fail to notify the Andover Service
               a year, or more often as new treatments, applications     Center within the required time frame as specified
               and technologies are adopted as generally accepted        in the Notification Requirements chart that starts on
               professional medical practice. These criteria are         page 21, your benefits may be reduced by as much
               evidence-based, whenever possible. Managed Care           as $500. The purpose of notifying the Plan is to give
               Program staff will inform you or your provider in         the Plan sufficient time to determine if the proposed
               advance regarding what services will be covered.          service will be covered. This process minimizes your
                                                                         risk of incurring charges for services that are not
               The Managed Care Program staff includes patient           covered by the Plan.
               advocates who are registered nurses, as well as
               other nurse reviewers and physician advisors. To
               determine medical necessity, nurses speak with your
               physicians, hospital staff, and/or other health care




               20
Managed Care Program


When you call the Plan to give notification of                   •	 The name, address and phone number of
an admission or service, please have the following                  the facility or vendor, as well as the fax number
information available:                                              if possible
•	 The hospital admission date or the start of                   Please refer to the following chart for specific
   service date                                                  notification requirements and responsibilities.
•	 The name, address and phone number of the
   admitting or referring physician, as well as
   the fax number if possible




                                                                                                                             Managed Care
( Managed Care Notification Requirements†

 Treatment / Service                                            Notification Requirement
 An Overnight Hospital Stay:
 •	 Non-emergency	admission                                     At least 7 calendar days before the admission
 •	 Emergency	admission                                         Within 24 hours (next business day)
 •	 Maternity	admission                                         Within 24 hours (next business day)
 Organ Transplants: Liver, lung, kidney, heart,                 At least 21 calendar days before
 bone marrow, simultaneous kidney and pancreas,                 transplant-related services begin
 all other
 Durable Medical Equipment:                                     At least one business day before ordering
 (if the purchase price exceeds $500 or the                     the equipment
 expected rental charges will exceed $500
 over the period of use)
 Exception: No notification is required for oxygen
 and oxygen equipment.
 Home Health Care provided by:                                  At least one business day before
 •	 Home	Health	Agencies                                        the services begin
 •	 Visiting	Nurse	Associations
 •	 Home	Infusion	Therapy	Companies
 •	 Private	Duty	Nurses
 Manipulative Therapy for children under age 13                 At least one business day before
 provided by:                                                   your first appointment date
 •	 Chiropractors
 •	 Medical	and	Osteopathic	Physicians
 Physical Therapy                                               At least one business day before
                                                                your first appointment date
 Occupational Therapy                                           At least one business day before
                                                                your first appointment date



( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300.
† Claims submission does not constitute notification.


                                                                                                                        21
               Managed Care Program


               ( Managed Care Notification Requirements† (continued)

                 Treatment / Service                                                  Notification Requirement
                Selected Procedure Review: (Some of the                               At least seven (7) calendar days before the
                procedures listed below may be performed                              procedure for non-emergency procedures. If you
                in a doctor’s office.)                                                are not sure whether the procedure is subject to
                                                                                      these notification requirements, please call the
                                                                                      Andover Service Center at (800) 442-9300.
                Procedure                                                             Definition
                Cardioverter-Defibrillator Implantation                               Surgical implantation of a device to continuously
Managed Care




                                                                                      monitor the heart rhythm to detect and correct
                                                                                      abnormal heart rhythms
                Certain Drugs Administered by Infusion:                               Administration	of	fluid	via	a	vein	or	
                                                                                      subcutaneous tissue
                •	 Immune	globulin                                                    An agent that is used for the treatment of
                                                                                      inflammatory,	autoimmune	or	other	diseases	
                •	 Infliximab	(Remicade)                                              An	agent	used	to	treat	certain	inflammatory	
                                                                                      conditions	such	as	arthritis,	inflammatory	
                                                                                      bowel disease and other diseases
                Hyperbaric Oxygen Therapy                                             Administration of pure oxygen at higher than
                                                                                      atmospheric pressure
                Intensity Modulated Radiation Therapy (IMRT)1                         A type of radiation that shapes the radiation beams
                                                                                      to closely approximate the shape of the tumor
                Knee Meniscal Transplant                                              Transplant of special cartilage into the knee to treat
                                                                                      certain types of knee pain and problems
                Sinus Surgery, Including Endoscopy                                    Any procedure by any method that opens, removes
                                                                                      or treats the nasal sinuses, including the use of
                                                                                      an endoscope
                Spinal Cord Stimulator and                                            Implantation of a device that delivers electrical
                Neuromodulator Implantation                                           current directly to specific areas of the spinal
                                                                                      cord with implanted electrodes, to treat pain or
                                                                                      urinary incontinence




               1 Ask your provider what kind of radiation therapy you will be getting to find out if it is IMRT.
               ( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300.
               † Claims submission does not constitute notification.


               22
Managed Care Program


( Managed Care Notification Requirements† (continued)

Procedure                                                      Definition
Upper Gastrointestinal Endoscopy                               Examination	through	a	flexible	telescopic	tube	
                                                               (endoscope) of the upper gastrointestinal (UGI)
                                                               area (that is, the esophagus, stomach, and
                                                               duodenum) for diagnosis and/or treatment
Surgical Treatments of the Back
(including but not limited to the following
procedures and any other spinal instrumentation




                                                                                                                           Managed Care
not otherwise specified):
•	 Discectomy	of	the	Lumbosacral	Spine                         Surgical procedure to remove a disc from the back
   P
•			 ercutaneous	and	Endoscopic	Discectomy                     Procedures on the spine using small incisions
   and other minimally invasive procedures                     through the skin and probes, endoscopes or
   to treat back pain                                          catheters to perform procedures
   L
•	 	 aminectomy/Laminotomy	of	the	                             Any surgical procedure removing portions of the
   Lumbosacral Spine                                           vertebra to relieve pressure on the spinal cord or
                                                               nerve roots in the lower back
•	 Spinal	Fusion	of	the	Lumbosacral	Spine	                     Surgical procedures in which two or more of the
                                                               vertebrae in the lower back are fused together
   S
•	 	 pinal	Instrumentation	of	the	                             Any surgical procedure by any method to relieve
   Lumbosacral Spine                                           pressure on the spinal cord or nerve roots in the
                                                               lumbosacral spine (lower back)
•	 Vertebroplasty                                              Injection of material into the center of a collapsed
                                                               spinal vertebra to repair fractures

CT Scans – Computerized Axial Tomography:
•	 Abdomen	and/or	Pelvis                                       Special computerized X-ray of the abdomen
                                                               or pelvis
•	 Cervical	Spine                                              Special computerized X-ray of the neck
•	 Thoracic	Spine	                                             Special computerized X-ray of the middle back
•	 Lumbosacral	Spine                                           Special computerized X-ray of the lower back
•	 Thoracic	Cavity                                             Special computerized X-ray of the chest and heart,
                                                               and CT scan angiogram of the thoracic cavity




( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300.
† Claims submission does not constitute notification.


                                                                                                                      23
               Managed Care Program


               ( Managed Care Notification Requirements† (continued)

                Procedure                                                      Definition
                MRI – Magnetic Resonance Imaging:
                •	 Abdomen	and/or	Pelvis	                                      Imaging study of the abdomen or pelvis
                •	 Breast                                                      Imaging study of the breast
                •	 Knee	                                                       Imaging study of the knee
                •	 Cervical	Spine                                              Imaging study of the neck
Managed Care




                •	 Thoracic	Spine	                                             Imaging study of the middle back
                •	 Lumbosacral	Spine                                           Imaging study of the lower back
                •	 Thoracic	Cavity                                             Imaging study of the chest
                PET Scan of any part of the body                               Specialized imaging to produce three-dimensional
                                                                               images of parts of the body
                SPECT Scan of any part of the body                             Specialized three-dimensional imaging of various
                                                                               tissues and organs

               ( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300.
               † Claims submission does not constitute notification.



               Utilization Management Program                                   Upon notification to the Andover Service Center,
                                                                                a patient advocate may contact your physician
               Inpatient Hospitalizations                                       and/or your physician’s representative to assist
               Initial Review                                                   in determining the medical necessity and
               The Plan must review and determine the medical                   appropriateness of the treatment plan and setting.
               necessity of all inpatient hospital admissions. You              You and your physician will each receive a written
               or someone acting on your behalf must initiate this              notice telling you if the Plan has confirmed the
               process by calling the Andover Service Center at                 medical necessity and appropriateness of the
               (800) 442-9300 at least seven (7) days in advance of             admission. This notice will also specify the initial
               a non-emergency admission, and within 24 hours                   length of stay approved for the admission.
               of, or the next business day after, an emergency or
               maternity admission.                                             If the patient advocate cannot confirm (1) the medical
                                                                                necessity and appropriateness of the treatment,
               The purpose of this process is to inform you                     (2) the inpatient hospital setting, or (3) the anticipated
               whether the admission will be considered for                     length of stay, your physician will be offered the
               benefits under the Plan prior to a non-emergency                 opportunity to speak with a physician advisor
               admission, or as soon as possible after an                       before the Plan makes a final decision. If the Plan
               emergency or maternity admission. Calling the                    determines that the admission is not medically
               Andover Service Center minimizes your risk of                    necessary and appropriate, the patient advocate will
               incurring charges for non-covered services.                      promptly notify you, your physician and the hospital.




               24
Managed Care Program


Continued Stay Review                                      Please note that if a covered item is not available
Your physician may recommend that you stay in              through a preferred vendor, although it is
the hospital beyond the initial number of days             authorized, it will only be covered at 80% of the
that the Plan has approved. In this case, the Plan         allowed amount after the calendar year deductible.
will determine whether a continued hospital stay
                                                           Home Infusion Therapy and Home Health Care
is medically necessary and appropriate.
                                                           When a physician prescribes home infusion therapy
You do not have to contact the Plan if your physician      as described in “Plan Definitions” or other home
recommends that you stay in the hospital beyond            health care services, the Plan must be notified at
the initial number of days approved by the Plan.           least one business day before services begin.
During the continued stay review, the patient
                                                           Upon notification, a patient advocate may call your




                                                                                                                    Managed Care
advocate will work with the hospital staff to facilitate
                                                           health care provider to obtain clinical information
planning for care that may be required after
                                                           that will be used to determine the medical
your discharge.
                                                           appropriateness of the home health care services.
If the patient advocate cannot confirm the medical         A patient advocate will notify you in writing
necessity and appropriateness of the treatment for         regarding whether the Plan will authorize
a continued hospitalization, your physician will           coverage for the services.
be offered the opportunity to speak with a physician
advisor before the Plan makes a final decision.            Manipulative Therapy
If the Plan determines that the continued stay is          Manipulative therapy refers to any hands-on
not medically necessary and appropriate, the patient       treatment provided by a chiropractor or a medical
advocate will promptly notify you, your physician          or osteopathic physician. For children under age 13,
and the hospital.                                          the Plan must be notified at least one (1) business
                                                           day before the services begin. Upon notification,
Durable Medical Equipment over $500                        a patient advocate may contact your health care
Any Durable Medical Equipment (DME) – other                provider to obtain clinical information that will be
than oxygen and oxygen equipment – ordered by              used to determine the medical appropriateness
a physician that is expected to cost more than $500        of the manipulative therapy services. Note: No prior
is subject to Plan review. The $500 cost may be            notification is required for manipulative therapy
the result of either the purchase price or the total       services for adults and children age 13 and over.
rental charges.                                            Physical Therapy
The Plan must be notified at least one (1) business        When a physician prescribes physical therapy
day before the equipment is ordered from the               services for you or for your dependent(s), the Plan
equipment provider. Upon notification, a patient           must be notified one (1) business day before the
advocate may contact your health care provider             date of your first appointment. A patient advocate
to obtain clinical information that will be used           may contact your health care provider to obtain
to determine the medical appropriateness of the            clinical information that will be used to determine
equipment. A patient advocate will notify you in           the medical appropriateness of the physical therapy
writing regarding whether the Plan will authorize          services.
coverage for the equipment.                                Physical therapy must be ordered by a physician,
If you obtain equipment through a preferred vendor,        and a copy of the order must be made available to
the authorized item will be covered at 100% of the         the Plan upon request.
allowed amount after the calendar year deductible.




                                                                                                               25
               Managed Care Program


               Occupational Therapy                                      warrants an immediate reconsideration, either party
               When a physician prescribes occupational therapy          may request reconsideration of that determination
               services for you or for your dependent(s), the Plan       over the telephone on an expedited basis.
               must be notified one (1) business day before the
                                                                         For an immediate reconsideration, the Andover
               date of your first appointment. A patient advocate
                                                                         Service Center must receive requests and all
               may contact your health care provider to obtain
                                                                         supporting information within three (3) business
               clinical information that will be used to determine
                                                                         days of the initial notification of denial. The
               the medical appropriateness of the occupational
                                                                         reconsideration will be completed within
               therapy services.
                                                                         two (2) business days of receipt of all necessary
               Occupational therapy must be ordered by a                 supporting documentation. The decision is then
Managed Care




               physician, and a copy of the order must be made           communicated in writing to the patient and the
               available to the Plan upon request.                       patient’s health care provider.

               Selected Procedures                                       If the denial is upheld, the patient can take the next
               Members scheduled on a non-emergency basis for            step and appeal the decision. Please see Appendix H
               one of the selected procedures listed on pages 22-24      for instructions on how to file an appeal.
               must notify the Plan at least seven (7) calendar days
               before the scheduled date of the procedure. The           Medical Case Management Program
               Plan requires notification, whether the procedure
                                                                         The Medical Case Management Program facilitates
               is being done in a hospital on an inpatient or
                                                                         the timely provision of appropriate, cost-effective,
               outpatient basis, in a freestanding facility or in
                                                                         quality health care services that are tailored to meet
               a physician’s office.
                                                                         an individual’s health care needs. A medical case
               If you are scheduled to have a procedure or special       manager is a registered nurse with the expertise to
               test done and you do not know the medical term            assist you and your family when you are faced with
               for it, ask your physician to call the Andover            a serious medical problem such as a stroke, cancer,
               Service Center at (800) 442-9300 to find out if prior     spinal cord injury or another condition that requires
               notification is needed, or check the list on pages        multiple medical services.
               22-24. Upon notification, a patient advocate may
                                                                         The medical case manager will:
               contact your physician to obtain clinical information
               that will be used to determine the medical necessity      •	 Help you and your family cope with the stress
               of the planned procedure and the appropriateness             associated with an illness or injury by facilitating
               of the setting in which it will be provided.                 discussions about health care planning, and
                                                                            enhance the coordination of services among
               If the patient advocate cannot confirm the medical
                                                                            multiple providers
               necessity and appropriateness of the planned
               procedure, your physician will be offered the             •	 Work with the attending physician and other
               opportunity to speak with a physician advisor before         involved health care providers to evaluate the
               the Plan makes a final decision.                             present and future health care needs of the patient
               Reconsideration Process                                   •	 Provide valuable information regarding available
               If an initial denial occurs before or while health care      resources for the patient
               services are being provided, and the attending
               physician or patient believes that the determination




               26
Managed Care Program


•	 Work with the mental health/substance abuse           Transplants at Quality Centers are covered at
   benefits administrator when you or your               100% after the applicable copay and deductible.
   dependent’s condition requires both medical and       Transplants at other hospitals are covered at 80%
   mental health services, to coordinate services        after the applicable copay and deductible. Although
   and maximize your benefits under the Plan             you have the freedom to choose any health care
                                                         provider for these procedures, you can maximize
•	 Explore alternative funding sources or other
                                                         your benefits when you use one of these Quality
   resources in cases where medical necessity exists
                                                         Centers. You or someone on your behalf should
   but there is a limit to coverage under the Plan
                                                         notify the Plan as soon as your physician
•	 Facilitate the management of chronic disease          recommends a transplant evaluation.
   states by promoting education, wellness




                                                                                                                     Managed Care
                                                         A medical case manager is available to support the
   programs, self-help and prevention
                                                         patient and family before the transplant procedure
•	 Promote the development of an appropriate plan        and throughout the recovery period. To speak
   of care to ease the transition from a stay in a       with a medical case manager, call (800) 442-9300.
   facility to the return home                           He or she will:
Coronary Artery Disease Secondary                        •	 Assess the patient’s ongoing needs
Prevention Program                                       •	 Coordinate services while the patient is awaiting
The Coronary Artery Disease Secondary Prevention            a transplant
Program is designed to help you make the necessary
lifestyle changes that can reduce your cardiac risk      •	 Help the patient and family to optimize
factors. It is available to members with a history of       Plan benefits
heart disease. The program is available through the      •	 Maintain communication with the
Medical Case Management Program. You may call               transplant team
a medical case manager to ask about your eligibility
and the available programs.                              •	 Facilitate transportation and housing
                                                            arrangements, if needed
Quality Centers and Designated                           •	 Facilitate discharge planning alternatives
Hospitals for Transplants                                •	 Coordinate home care plans as necessary
The Plan has designated certain hospitals as Quality
                                                         •	 Explore alternative funding sources or other
Centers for organ transplants. These hospitals were
                                                            resources in cases where there is need but
chosen for their specialized programs, experience,
                                                            there are limited benefits under the Plan
reputation and ability to provide high quality
transplant care. The purpose of this program is
to facilitate the provision of timely, cost-effective,
quality services to eligible Plan members at
specialized facilities.




                                                                                                                27
                       Benefit Highlights
                     A Summary of Your Medical Benefits                      The book symbol & next to each service listed
                                                                             in the “Benefits Highlights” section gives you the
                     This section contains a summary of your medical         corresponding page in the “Description of Covered
                     benefits under the Community Choice Plan,               Services” section or other sections where this
                     as follows:                                             benefit is more fully described.
                     •	 The level of benefits                                The telephone symbol ( you see throughout this
                     •	 Any coinsurance, copays, or deductibles you are      Handbook lets you know that, to obtain the
                        responsible for paying in connection with a          maximum level of benefits for this type of service,
                        service or supply (for copay and deductible          you must call the Andover Service Center at
                        amounts, please refer to the “Your Costs” section)   (800) 442-9300. Failure to do so may result in a
                                                                             reduction in benefits of up to $500. However, you
                     •	 Any limits on the maximum number of visits           do not need to call the Plan if you are outside the
                        allowed per calendar year                            continental United States (the contiguous 48 states).
                     •	 Any maximum dollar amounts per calendar year         Please refer to the “Managed Care Program” section
                        that are associated with a service or supply         of this Handbook (the preceding section) for more
                                                                             information regarding the notification requirements
                     Important: The information contained in this            associated with these benefits.
Benefit Highlights
Covered Services




                     section is only a summary of your medical benefits.
                     For additional details of your medical plan benefits,   The computer symbol : you see throughout this
                     please refer to the “Description of Covered Services”   Handbook indicates that information on the
                     section of this Handbook.                               highlighted topic is available on the Plan’s website,
                                                                             www.unicarestateplan.com.




                     28
Benefit Highlights


Summary of Covered Hospital-Based Services
                                              Community Choice Hospitals                Other Hospitals

 ( Inpatient Hospital Services
 in an Acute Medical, Surgical or Rehabilitation Facility                               & Also see page 37
 Semi-Private Room, ICU,                      100% after the inpatient hospital         80% after the non-Community
 CCU and Ancillary Services                   quarterly copay and after the             Choice inpatient hospital copay
                                              calendar year deductible                  per admission and after the
                                                                                        calendar year deductible
 Medically Necessary                          100% for the first 90 days in a           80% for the first 90 days in
 Private Room                                 calendar year after the inpatient         a calendar year after the
                                              hospital quarterly copay and              non-Community Choice inpatient
                                              after the calendar year                   hospital copay per admission
                                              deductible; then 100% at                  and after the calendar
                                              the semi-private level                    year deductible; then 80%
                                                                                        at the semi-private level
 Inpatient Diagnostic Laboratory              100% after the calendar                   80% after the calendar
 and Radiology (including                     year deductible                           year deductible
 high-tech imaging)




                                                                                                                                      Covered Services
                                                                                                                                      Benefit Highlights
                                                                                        & Also see page 52 and
 ( Select Complex Inpatient Procedures and Neonatal ICUs                                Appendix D
 Select Complex Inpatient                     100% after the inpatient hospital         80% after the non-Community
 Procedures and Neonatal ICUs                 quarterly copay and after the             Choice inpatient hospital copay
                                              calendar year deductible at a             per admission and after the
                                              Designated Hospital or                    calendar year deductible
                                              Community Choice hospital




( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
Care Program” section for specific notification requirements and responsibilities.
For deductible and copay amounts, see the charts in the “Your Costs” section. All services must be medically necessary and all
charges will be subject to the allowed amount.



                                                                                                                                 29
                     Benefit Highlights


                     Summary of Covered Hospital-Based Services
                                                                   Quality Centers and Designated
                                                                   Hospitals for Transplants                 Other Hospitals

                      ( Transplants                                                                          & Also see page 43
                                                                   100% after the inpatient hospital         At a Community Choice
                                                                   quarterly copay and after the             Hospital: 80% after the inpatient
                                                                   calendar year deductible                  hospital quarterly copay and after
                                                                                                             the calendar year deductible
                                                                                                             Note: The 20% coinsurance
                                                                                                             does not count toward the
                                                                                                             out-of-pocket maximum
                                                                                                             At a Non-Community Choice
                                                                                                             Hospital: 80% after the
                                                                                                             non-Community Choice inpatient
                                                                                                             hospital copay per admission and
                                                                                                             after the calendar year deductible
                                                                                                             Note: The 20% coinsurance
                                                                                                             does not count toward the
Benefit Highlights
Covered Services




                                                                                                             out-of-pocket maximum
                                                                   Community Choice Hospitals                Other Hospitals

                      Other Inpatient Facilities                                                             & Also see page 37
                         S
                      •	 	 ub-Acute	Care	Hospitals/                80% after the calendar year               80% after the calendar year
                         Facilities                                deductible, up to a maximum of            deductible, up to a maximum of
                         T
                      •	 	 ransitional	Care	Hospitals/             45 days per calendar year                 45 days per calendar year
                         Facilities
                                                                   Note: The 20% coinsurance                 Note: The 20% coinsurance
                         L
                      •	 	 ong-Term	Care	Hospitals/
                         Facilities
                                                                   does not count toward the                 does not count toward the
                         C
                      •	 	 hronic	Disease	Hospitals/
                                                                   out-of-pocket maximum                     out-of-pocket maximum
                         Facilities
                         S
                      •	 	 killed	Nursing	Facilities

                      Coronary Artery Disease (CAD) Secondary Prevention Program                             & Also see page 27
                      Designated Programs                          90% after the calendar year               90% after the calendar year
                      available through Medical                    deductible                                deductible
                      Case Management
                                                                   Note: The 10% coinsurance does            Note: The 10% coinsurance does
                                                                   not count toward the out-of-              not count toward the out-of-
                                                                   pocket maximum                            pocket maximum
                      All Other Programs                           Not covered                               Not covered


                     ( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
                     Care Program” section for specific notification requirements and responsibilities.
                     For deductible and copay amounts, see the charts in the “Your Costs” section. All services must be medically necessary and all
                     charges will be subject to the allowed amount.


                     30
Benefit Highlights


Summary of Covered Hospital-Based Services
                                              Community Choice Hospitals                 Other Hospitals

 Outpatient Hospital Services                                                            & Also see pages 38-43
 Emergency Room                               100% after the emergency room              100% after the emergency room
                                              copay and after the calendar               copay and after the calendar
                                              year deductible; copay waived              year deductible; copay waived
                                              if admitted                                if admitted
 High-Tech Imaging (such as                   100% after the calendar                    100% after the calendar
 MRIs, CT scans and PET                       year deductible                            year deductible
 scans) as part of Emergency
 Room Treatment

 ( All Other High-Tech Imaging                100% after the high-tech imaging           100% after the non-Community
 (such as MRIs, CT scans and                  copay per scan and after                   Choice high-tech imaging copay
 PET scans)                                   the calendar year deductible;              per scan and after the calendar
                                              maximum of one copay per day               year deductible; maximum of
                                                                                         one copay per day
 All Other Radiology                          100% after the calendar                    100% after the outpatient
                                              year deductible                            radiology copay and after the




                                                                                                                                       Covered Services
                                                                                                                                       Benefit Highlights
                                                                                         calendar year deductible1
 Diagnostic Laboratory Testing                100% after the calendar                    100% after the outpatient lab
                                              year deductible                            copay and after the calendar
                                                                                         year deductible1
 ( Surgery                                    100% after the outpatient surgery          80% after the non-Community
                                              quarterly copay and after the              Choice outpatient surgery copay
                                              calendar year deductible                   per occurrence and after the
                                                                                         calendar year deductible
 ( Physical Therapy and                       100% after the copay                       100% after the copay
 ( Occupational Therapy
 Speech Therapy                               100%, up to a maximum benefit              100%, up to a maximum benefit
                                              of $2,000 per calendar year                of $2,000 per calendar year
 Chemotherapy                                 100% after the calendar                    100% after the calendar
                                              year deductible                            year deductible
 ( Radiation Therapy                          100% after the calendar                    100% after the calendar
                                              year deductible                            year deductible
 Other Outpatient                             100% after the calendar                    100% after the calendar
 Hospital Services                            year deductible                            year deductible

1 If you receive both laboratory and X-ray services at a non-Community Choice hospital in the same day, you will only be responsible
for one copay.
( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
Care Program” section for specific notification requirements and responsibilities.
For deductible and copay amounts, see the charts in the “Your Costs” section. All services must be medically necessary and all
charges will be subject to the allowed amount.



                                                                                                                                 31
                     Benefit Highlights


                     Summary of Covered Non-Hospital-Based Services
                                                                                         All Providers

                      Physician Services                                                 & Also see page 42
                      Inpatient                                                          100% after the calendar year deductible
                      Emergency Room Treatment                                           100% after the calendar year deductible
                      Office, Home or Outpatient Hospital                                100% after the applicable office visit copay
                      ( Surgery at a Freestanding Ambulatory                             100% after the calendar year deductible
                      Surgical Center or Physician’s Office

                      ( Chiropractic Care or Treatment                                   80% after the chiropractic visit copay; maximum
                                                                                         benefit of $40 per visit, 20 visits per calendar year
                                                                                         Note: The 20% coinsurance does not count toward
                                                                                         the out-of-pocket maximum
                      ( Physical Therapy and
                      ( Occupational Therapy                                             & Also see page 42
                                                                                         100% after the copay
Benefit Highlights
Covered Services




                     ( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
                     Care Program” section for specific notification requirements and responsibilities.
                     For deductible and copay amounts, see the charts in the “Your Costs” section. All services must be medically necessary and all
                     charges will be subject to the allowed amount.



                     32
Benefit Highlights


Summary of Covered Non-Hospital-Based Services
                                                                    All Providers

 Preventive Care                                                    & See Appendix I, “Preventive Care Schedule”
                                                                    100%
 Licensed Retail Medical Clinics at Retail
 Pharmacies                                                         & Also see page 42
                                                                    100% after the copay
 Family Planning Services                                           & Also see page 40
 Office Visits                                                      100%
 Procedures                                                         100%
 Diagnostic Laboratory Tests
 (non-hospital based)                                               & Also see page 42
                                                                    100% after the calendar year deductible
 Radiology (non-hospital based)                                     & Also see page 42




                                                                                                                                       Covered Services
                                                                                                                                       Benefit Highlights
 ( High-Tech Imaging (such as MRIs, CT scans                        100% after the high-tech imaging copay per scan
 and PET scans)                                                     and after the calendar year deductible; maximum
                                                                    of one copay per day1

 All Other Radiology                                                100% after the calendar year deductible




1 If you receive both laboratory and X-ray services at a non-Community Choice hospital in the same day, you will only be responsible
for one copay.
( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
Care Program” section for specific notification requirements and responsibilities.
For deductible and copay amounts, see the charts in the “Your Costs” section. All services must be medically necessary and all
charges will be subject to the allowed amount.



                                                                                                                                 33
                     Benefit Highlights


                     Summary of Covered Non-Hospital-Based Services
                                                                                         All Providers

                      ( Private Duty Nursing                                             & Also see page 42
                      Provided in a Home Setting Only                                    80% after the calendar year deductible for a
                                                                                         registered nurse, up to a calendar year maximum
                                                                                         benefit of $8,000. Of this $8,000, up to $4,000
                                                                                         may be for licensed practical nurse services if
                                                                                         no registered nurse is available.
                                                                                         Note: The 20% coinsurance does not count toward
                                                                                         the out-of-pocket maximum
                      ( Home Health Care                                                 & Also see page 40
                      Medicare-Certified Home Health Agencies and                        80% after the calendar year deductible
                      Visiting Nurse Associations1,2

                      ( Home Infusion Therapy                                            & Also see pages 25, 54
                      Preferred Vendors2                                                 100% after the calendar year deductible
                      Other Vendors                                                      80% after the calendar year deductible
Benefit Highlights
Covered Services




                                                                                         Note: The 20% coinsurance does not count
                                                                                         toward the out-of-pocket maximum
                      ( Hospice                                                          & Also see page 43
                      Medicare-Certified Hospice                                         100% after the calendar year deductible
                      Bereavement Counseling                                             80% after the calendar year deductible, up to
                                                                                         a maximum benefit of $1,500 per family
                                                                                         Note: The 20% coinsurance does not count
                                                                                         toward the out-of-pocket maximum




                     1 A program is available to enhance the benefit for home health care by using designated providers.
                     2 For a list of the Plan’s preferred vendors, see Appendix J.
                     ( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
                     Care Program” section for specific notification requirements and responsibilities.
                     For deductible and copay amounts, see the charts in the “Your Costs” section. All services must be medically necessary and all
                     charges will be subject to the allowed amount.



                     34
Benefit Highlights


Summary of Covered Non-Hospital-Based Services
                                                                      All Providers

 Early Intervention Services for Children                             & Also see page 40
 Programs approved by the Department                                  80% after the calendar year deductible, up to a
 of Public Health                                                     maximum benefit of $5,200 per child per calendar
                                                                      year, and a lifetime maximum benefit of $15,600
                                                                      Note: The 20% coinsurance does not count toward
                                                                      the out-of-pocket maximum
 Ambulance                                                            & Also see pages 39, 49
                                                                      100% after the calendar year deductible
 ( Durable Medical Equipment                                          & Also see page 44
 Preferred Vendors        1
                                                                      100% after the calendar year deductible
 Other Vendors                                                        80% after the calendar year deductible
                                                                      Note: The 20% coinsurance does not count toward
                                                                      the out-of-pocket maximum




                                                                                                                                             Covered Services
                                                                                                                                             Benefit Highlights




1 If an item is not available through a preferred vendor and you obtain it from another provider, it will be covered at 80%. For a list of
the Plan’s preferred vendors, see Appendix J.
( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
Care Program” section for specific notification requirements and responsibilities.
For deductible and copay amounts, see the charts in the “Your Costs” section. All services must be medically necessary and all
charges will be subject to the allowed amount.



                                                                                                                                       35
                     Benefit Highlights


                     Summary of Covered Non-Hospital-Based Services
                                                                                        All Providers
                      Hospital-Based Personal Emergency
                      Response Systems (PERS)                                           & Also see page 44
                      Installation                                                      80% after the calendar year deductible, up to
                                                                                        a maximum benefit of $50
                                                                                        Note: The 20% coinsurance does not count
                                                                                        toward the out-of-pocket maximum
                      Rental Fee                                                        80% after the calendar year deductible, up to
                                                                                        a maximum benefit of $40 per month
                                                                                        Note: The 20% coinsurance does not count
                                                                                        toward the out-of-pocket maximum
                      Prostheses1                                                       & Also see page 42
                                                                                        80% after the calendar year deductible
                      Braces   2
                                                                                        & Also see page 39
                                                                                        80% after the calendar year deductible
                      Hearing Aids                                                      & Also see page 40
Benefit Highlights
Covered Services




                                                                                        100% of the first $500; then 80% of the next $1,500,
                                                                                        up to a maximum of $1,700 every two years
                                                                                        Note: The 20% coinsurance does not count toward
                                                                                        the out-of-pocket maximum
                      Eyeglasses / Contact Lenses                                       & Also see page 50
                                                                                        80% after the calendar year deductible. Limited
                                                                                        to the initial set within six months following
                                                                                        cataract surgery.
                      Routine Eye Examinations
                      (including refraction and glaucoma testing)                       & Also see page 42
                                                                                        100% after the applicable copay. Covered once
                                                                                        every 24 months.
                      All Other Covered Medical Services                                & Also see pages 39-43
                                                                                        80% after the calendar year deductible


                     Prescription Drug Plan – Benefits Administered by CVS Caremark
                     & See page 67. For more information, call (877) 876-7214 (toll free).
                     Mental Health, Substance Abuse and Enrollee Assistance Programs – Benefits Administered
                     by United Behavioral Health
                     & See page 79. For more information, call (888) 610-9039 (toll free).
                     1	Breast	prostheses	are	covered	at	100%	after	the	calendar	year	deductible.	Wigs	are	not	subject	to	the	calendar	year	deductible.
                     2 Orthopedic shoe(s) with attached brace is covered at 100% after the calendar year deductible.
                     For deductible and copay amounts, see the charts in the “Your Costs” section. All services must be medically necessary and all
                     charges will be subject to the allowed amount.



                     36
  Description of Covered Services
The following pages contain descriptions of various                  Services at Other Inpatient Facilities
covered services under the Plan. Please refer to
the “Benefit Highlights” section for information                     Other inpatient facilities include:
regarding benefit percentages and maximums,                          •	 Sub-Acute Care Hospitals/Facilities
copays, coinsurance amounts, deductibles, out-of-                    •	 Transitional Care Hospitals/Facilities
pocket maximum amounts and durations of benefits                     •	 Long-Term Care Hospitals/Facilities
that apply to these covered services. (For copay                     •	 Chronic Disease Hospitals/Facilities
and deductible amounts, see the charts in the “Your                  •	 Skilled Nursing Facilities
Costs” section.)                                                     Covered charges for these facilities include the
The “Benefit Highlights” section also shows you the                  following services:
difference in the level of benefits when you use                     1. Room and board
Community Choice hospitals versus non-Community
Choice hospitals. For information on the Plan’s                      2. Routine nursing care, but not including the
medical review requirements and to find out when                        services of a private duty nurse or other private
prior authorization is needed, please refer to the                      duty attendant
“Managed Care Program” section.                                      3. Physical, occupational and speech therapy
                                                                        provided by the facility or by others under




                                                                                                                                 Covered Services
                                                                                                                                 Benefit Highlights
( Inpatient Hospital Services                                           arrangements with the facility
Charges for the following services qualify as covered                4. Such drugs, biologicals, medical supplies,
hospital charges if the services are for a hospital stay.               appliances, and equipment as are ordinarily
1. Room and board provided to the patient                               provided by the facility for the care and
                                                                        treatment of its patients
2. Anesthesia, radiology and pathology services
                                                                     5. Medical social services
3. Hospital pre-admission testing if you or your
   covered dependent(s) is scheduled to enter the                    6. Diagnostic and therapeutic services furnished to
   same hospital where the tests are performed                          patients of the facility by a hospital or any other
   within seven (7) days of the testing. If the                         health care provider
   hospital stay is cancelled or postponed after                     7. Other medically necessary services as are
   the tests are performed, the charges will still                      generally provided by such treatment facilities
   be covered as long as the physician presents
   a satisfactory medical explanation.                                 Coverage in “Other Inpatient Facilities”
                                                                       To qualify for coverage in “Other Inpatient
4. Medically necessary services and supplies                           Facilities,” the purpose of the care in these
   charged by the hospital, except for special                         facilities must be the reasonable improvement in
   nursing or physician services                                       the patient’s condition. A physician must certify
                                                                       that the patient needs and receives, at a
5. Physical, occupational and speech therapy
                                                                       minimum, skilled nursing or skilled rehabilitation
6. Diagnostic and therapeutic services                                 services on a daily or intermittent basis. Continuing
                                                                       care for a patient who has not demonstrated
                                                                       reasonable clinical improvement is not covered.


( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
Care Program” section for specific notification requirements and responsibilities.



                                                                                                                            37
                     Description of Covered Services


                     Emergency Treatment for an Accident                                      (b) The assistant surgeon is trained in a surgical
                                                                                                  specialty related to the procedure and is not
                     or Sudden/Serious Illness                                                    a fellow, resident or intern in training, and
                     An emergency is an illness or medical condition,
                                                                                              (c) The assistant surgeon serves as the first
                     whether physical or mental, that manifests itself
                                                                                                  assistant surgeon (second or third assistants
                     by symptoms of sufficient severity, including severe
                                                                                                  are not covered)
                     pain, that the absence of immediate medical
                     attention could reasonably be expected by a prudent                  3. Reconstructive breast surgery:
                     lay person, who possesses an average knowledge of
                                                                                              (a) All stages of breast reconstruction following
                     health and medicine, to result in serious jeopardy to
                                                                                                  a mastectomy
                     physical and/or mental health, serious impairment
                     to bodily functions, serious dysfunction of any                          (b) Reconstruction of the other breast to produce
                     bodily organ or part, or, in the case of pregnancy,                          a symmetrical appearance after mastectomy
                     a threat to the safety of a member or her
                                                                                              (c) Coverage for prostheses and treatment of
                     unborn child.
                                                                                                  physical complications of all stages of
                     Massachusetts provides a 911 emergency response                              mastectomy, including lymphedemas
                     system throughout the state. The Plan will cover
                                                                                              Benefits for reconstructive breast surgery will be
                     medical and transportation expenses incurred as
                                                                                              payable on the same basis as any other illness
                     a result of the emergency medical conditions in
                                                                                              or injury under the Plan, including the
                     accordance with the terms of the Plan. If you are
Benefit Highlights
Covered Services




                                                                                              application of appropriate copays, deductibles
                     faced with an emergency, call 911. In other states,
                                                                                              and coinsurance amounts. Several states have
                     check with your local telephone company about
                                                                                              enacted similar laws requiring coverage for
                     emergency access numbers. Keep emergency
                                                                                              treatment related to mastectomy. If the law of
                     numbers and the telephone numbers of your
                                                                                              your state is more generous than the federal law,
                     physicians in an easily accessible location.
                                                                                              your benefits will be paid in accordance with
                                                                                              your state’s law.
                     ( Surgical Services
                                                                                          4. All other reconstructive and restorative surgery,
                     The payment to a surgical provider for operative                        but limited to the following:
                     services includes the usual pre-operative, intra-
                     operative and post-operative care.                                       (a) Reconstruction of defects resulting from
                                                                                                  surgical removal of an organ or body part for
                     Charges for the following services qualify as covered                        the treatment of cancer. Such restoration must
                     surgical charges:                                                            be within five (5) years of the removal surgery.
                     1. Medically necessary surgical procedures when                          (b) Correction of a congenital birth defect that
                        performed on an inpatient or outpatient basis                             causes functional impairment for a minor
                        (hospital, physician’s office or freestanding                             dependent child.
                        ambulatory surgical center)
                     2. Services of an assistant surgeon when:
                          (a) Medically necessary




                     ( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
                     Care Program” section for specific notification requirements and responsibilities.



                     38
Description of Covered Services


Medical Services                                        9. Crutches – Replacement of such equipment is
                                                           covered when required due to pathological
Charges for the following services qualify as covered      change or normal growth.
medical charges, but only if they do not qualify as
covered hospital or surgical charges:                   10. Diabetes – Benefits will be paid for charges
                                                            incurred by a covered person for medically
1. Ambulance/Air Ambulance – Covered only in                necessary equipment, supplies and medications
   the event of an emergency and when medically             for the treatment of diabetes. Coverage will
   necessary. Benefits are payable only for                 include outpatient self-management training
   transportation to the nearest facility equipped          and patient management, as well as nutritional
   to treat the condition. Transportation to or             therapy.
   from medical appointments, including dialysis,
   is not a covered service.                               Coverage will apply to services and supplies
                                                           prescribed by a doctor for insulin dependent,
2. Anesthesia and its administration.                      insulin using, gestational and non-insulin using
3. Audiology Services – Expenses for the diagnosis         diabetes. The Plan will provide benefits for these
   of speech, hearing and language disorders are           services and supplies when prescribed by a
   covered when provided by a licensed audiologist         physician under the medical component of the
   when the services are provided in a hospital,           Plan or under the prescription drug plan as
   clinic or private office. Services provided in a        indicated below.
   school-based setting are not covered. The Plan          Diabetic drugs, insulin and the following




                                                                                                                Covered Services
                                                                                                                Benefit Highlights
   does not cover services that a school system            diabetic supplies are covered under the
   is obligated to provide under Chapter 766               prescription drug component of the Plan:
   in Massachusetts or under similar laws in
   other states.                                           (a)   Blood glucose monitors
                                                           (b)   Test strips for glucose monitors
4. Autism Spectrum Disorders – Benefits are                (c)   Insulin
   payable for charges incurred by a covered person        (d)   Syringes and all injection aids
   for medically necessary diagnosis and treatment         (e)   Lancets and lancet devices
   of autism spectrum disorders the same as those          (f)   Prescribed oral agents
   for any other physical condition. (See the “Mental      (g)   Glucose agents and glucagon kits
   Health, Substance Abuse and Enrollee Assistance         (h)   Urine test strips
   Programs” section for coverage details.)
                                                           The following diabetic supplies are covered
5. Braces – Replacement of such equipment is also          under the medical component of the Plan:
   covered when required due to pathological
   change or normal growth.                                (a) Blood glucose monitors, including voice
                                                               synthesizers for blood glucose monitors for
   Also see Orthotics.                                         use by legally blind persons
6. Cardiac Rehabilitation Treatment – Provided             (b) Test strips for glucose monitors
   by a cardiac rehabilitation program (see the
   definition on page 52).                                 (c) Laboratory tests, including glycosylated
                                                               hemoglobin (HbA1c) tests, urinary protein/
7. Certified Nurse Midwife Services – Provided in              microalbumin and lipid profiles
   the home or in a hospital.
                                                           (d) Insulin pumps and all related supplies
8. Circumcision – When provided for newborns up
   to 30 days from birth.                                  (e) Insulin infusion devices




                                                                                                          39
                     Description of Covered Services


                          (f) Syringes and all injection aids                                   comprehensive plan of care related to the
                                                                                                patient’s condition. In addition, the services
                          (g) Lancets and lancet devices
                                                                                                must be needed to ensure therapy or compliance
                          (h) Urine test strips                                                 or to provide the patient with the necessary
                                                                                                skills and knowledge involved in the successful
                          (i) Insulin measurement and administration
                                                                                                management of the patient’s condition.
                              aids for the visually impaired
                                                                                          11. Early Intervention Services for Children –
                          (j) Podiatric appliances for the prevention of
                                                                                              Coverage of medically necessary Early
                              complications associated with diabetes
                                                                                              Intervention Services for children from birth
                          Diabetes Self-Management Training                                   until they turn three years old includes
                          Diabetes self-management training and patient                       occupational therapy, physical therapy, speech
                          management, including medical nutritional                           therapy, nursing care, psychological counseling,
                          therapy, may be conducted individually or in                        and services provided by early intervention
                          a group, but must be provided by:                                   specialists or by licensed or certified health care
                                                                                              providers working with an Early Intervention
                          •	 An education program recognized by the
                                                                                              Services program approved by the Department
                             American Diabetes Association, or
                                                                                              of Public Health. See page 35 for benefit
                          •	 A health care professional who is a diabetes                     maximums.
                             educator certified by the National Certification
                                                                                          12. Family Planning Services – Office visits and
                             Board for Diabetes Educators
Benefit Highlights
Covered Services




                                                                                              procedures for the purpose of contraception.
                          Coverage will include all educational materials                     Office visits include evaluations, consultations
                          for such program. Benefits will be provided                         and follow-up care. Procedures include fitting
                          as follows:                                                         for a diaphragm or cervical cap; the insertion,
                                                                                              re-insertion, or removal of an IUD or
                          (a) Upon the initial diagnosis of diabetes
                                                                                              Levonorgestrel (Norplant); and the injection of
                          (b) When a significant change occurs in                             progesterone (Depo-Provera). FDA-approved
                              symptoms or conditions, requiring changes                       contraceptive drugs and devices are available
                              in self-management                                              through the prescription drug plan.
                          (c) When refresher patient management is                        13. Gynecological Visits – Annual gynecological
                              necessary, or                                                   examination, including Pap smear.
                          (d) When new medications or treatments                          14. Hearing Aids – When prescribed by a physician.
                              are prescribed                                                  See the “Benefit Highlights” section for the
                                                                                              benefit maximum.
                          As used in this provision, “patient management”
                          means educational and training services                         15. Hearing Screenings for newborns.
                          furnished to a covered person with diabetes in
                                                                                          16.   ( Home Health Care – Skilled nursing
                          an outpatient setting by a person or entity with
                                                                                                services provided under a plan of care prescribed
                          experience in the treatment of diabetes. This will
                                                                                                by a physician and delivered by a Medicare-
                          be in consultation with the physician who is
                                                                                                certified home health care agency. (Refer to the
                          managing the patient’s condition. The physician
                                                                                                definition of “Home Health Care” on page 54.)
                          must certify that the services are part of a



                     ( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
                     Care Program” section for specific notification requirements and responsibilities.



                     40
Description of Covered Services


   The following services are only covered if the     (c) Gamete Intrafallopian Transfer (GIFT)
   covered individual is receiving approved part-
                                                      (d) Zygote Intrafallopian Transfer (ZIFT)
   time, intermittent skilled care furnished or
   supervised by a registered nurse or licensed       (e) Natural Ovulation Intravaginal Fertilization
   physical therapist:                                    (NORIF)
   (a) Part-time, intermittent home health aide       (f) Cryopreservation of eggs as a component
       services consisting of personal care of            of covered infertility treatment (costs
       the patient and assistance with activities         associated with banking and/or storing
       of daily living                                    inseminated eggs are reimbursable only
                                                          upon the use of such eggs for covered
   (b) Physical, occupational, speech and
                                                          fertility treatment)
       respiratory therapy by the appropriate
       licensed or certified therapist                (g) Sperm, egg and/or inseminated egg
                                                          procurement and processing, and banking
   (c) Nutritional consultation by a
                                                          of sperm or inseminated eggs, to the extent
       registered dietitian
                                                          such costs are not covered by the donor’s
   (d) Medical social services provided by                insurer, if any
       a licensed medical social worker
                                                      (h) Donor sperm or egg procurement and
   (e) Durable medical equipment (DME) and                processing, to the extent such costs are not
       supplies provided as a medically necessary         covered by the donor’s insurer, if any




                                                                                                             Covered Services
                                                                                                             Benefit Highlights
       component of a physician-approved home
                                                      (i) Intracytoplasmic Sperm Injection (ICSI) for
       health services plan.
                                                          the treatment of male factor infertility
   However, the following charges do not qualify as
                                                      In Vitro Fertilization and other associated
   covered home health care charges:
                                                      infertility procedures, with the exception
   (a) Charges for custodial care or                  of artificial insemination, are limited to
       homemaking services                            a maximum of five (5) attempts (see the
                                                      definition of “Attempt” in “Plan Definitions”).
   (b) Services provided by you, a member of your
       family or any person who resides in your       The following are not considered
       home. Your family consists of you, your        covered services:
       spouse and your children, as well as
                                                      (a) Experimental infertility procedures
       brothers, sisters and parents of both you
       and your spouse.                               (b) Surrogacy
17. Infertility Treatment – Non-experimental          (c) Reversal of voluntary sterilization
    infertility procedures including, but not
                                                      (d) Procedures for infertility not meeting the
    limited to:
                                                          Plan’s definition (see page 54)
   (a) Artificial Insemination (AI) also known
                                                      Facility fees will be considered as covered
       as Intrauterine Insemination (IUI)
                                                      services by the Plan only from a licensed
   (b) In Vitro Fertilization and Embryo Placement    hospital or a licensed freestanding ambulatory
       (IVF-EP)                                       surgical center.




                                                                                                        41
                     Description of Covered Services


                     18. Laboratory Tests – Must be ordered by                                  medically necessary services. Any charges
                         a physician.                                                           for telephone and email consultations are
                                                                                                not covered.
                     19.   ( Manipulative Therapy – Chiropractic
                           or osteopathic manipulation used to treat                      26. Preventive Care – The Plan covers preventive
                           neuromuscular and/or musculoskeletal                               or routine level office visits or physical
                           conditions on a short-term basis when the                          examinations and other related preventive
                           potential for functional gains exists.                             services including those recommended by the
                                                                                              U.S. Preventive Services Task Force. Please see
                     20. Nurse Practitioners – Medically necessary
                                                                                              Appendix I for the complete preventive care
                         services provided in a hospital, clinic,
                                                                                              schedule.
                         professional office, home care setting, long-term
                         care setting or any other setting when services                  27.   ( Private Duty Nursing Care – Highly skilled
                         are provided by a nurse practitioner who is                            nursing care needed continuously during a
                         practicing within the scope of his/her license.                        block of time (greater than two hours) provided
                                                                                                by a registered nurse while you are confined to
                     21.   ( Occupational Therapy – By a registered
                                                                                                your home. You can also use an LPN (licensed
                           occupational therapist when ordered by
                                                                                                practical nurse) under some circumstances; see
                           a physician.
                                                                                                the “Benefit Highlights” section. Private duty
                     22. Orthotics – Covered when they meet the                                 nursing care must:
                         following criteria:
                                                                                                (a) Be medically necessary
Benefit Highlights
Covered Services




                           (a) Ordered by a physician
                                                                                                (b) Provide skilled nursing services
                           (b) Custom fabricated (molded and fitted) to
                                                                                                (c) Be exclusive of all other home health care
                               the patient’s body
                                                                                                    services, and
                     23. Oxygen and its administration.
                                                                                                (d) Not duplicate services that a hospital or
                     24.   ( Physical Therapy – Physical therapy used to                            facility is licensed to provide
                           treat neuromuscular and/or musculoskeletal
                                                                                          28. Prostheses – Replacement of such equipment is
                           conditions on a short-term basis when the
                                                                                              also covered when required due to pathological
                           potential for functional gain exists. The Plan
                                                                                              change or normal growth.
                           only covers one-on-one therapies rendered
                           by a registered physical therapist or certified                29.   ( Radiation Therapy – Includes radioactive
                           physical therapy assistant (under the direction                      isotope therapy and intensity modulated
                           of a physical therapist) and when ordered                            radiation therapy (IMRT).
                           by a physician.
                                                                                          30. Retail Medical Clinics – Charges for medically
                     25. Physician Services – Medically necessary                             necessary services for episodic, urgent care such
                         services provided by a licensed physician acting                     as treatment for an earache or sinus infection at
                         within the scope of that license providing such                      licensed retail medical clinics located at certain
                         services in the home, hospital, physician’s office,                  pharmacies. Flu vaccines may also be
                         or other medical facility. Charges by physicians                     administered at these clinics.
                         for their availability in case their services may
                                                                                          31. Routine Eye Examinations (including refraction
                         be needed are not covered services. The Plan
                                                                                              and glaucoma testing) – Covered once every
                         only pays physicians for the actual delivery of
                                                                                              24 months.

                     ( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
                     Care Program” section for specific notification requirements and responsibilities.



                     42
Description of Covered Services


32. Routine Foot Care – Charges for medically                        ( Transplants
    necessary routine foot care are covered if
    accompanied by medical evidence documenting:                     Benefits are payable, subject to deductibles,
                                                                     coinsurance, copays and limitations, for necessary
    •	 In the case of an ambulatory patient, an                      medical and surgical expenses incurred for the
       underlying condition causing vascular                         transplanting of a human organ. (To receive the
       compromise, such as diabetes, or                              maximum benefit, please refer to “Quality Centers
    •	 In the case of a non-ambulatory patient,                      and Designated Hospitals for Transplants” on
       a condition that is likely to result in significant           page 27.)
       medical complications in the absence of                       Human Organ Donor Services
       such treatment.                                               Benefits are payable, subject to deductibles, copays,
33. Speech-Language Pathology Services – Expenses                    coinsurance and limitations, for necessary expenses
    for the diagnosis and treatment of speech,                       incurred for delivery of a human organ (any part of
    hearing and language disorders are covered                       the human body, excluding blood and blood plasma)
    when provided by a licensed speech-language                      and medical expenses incurred by a person in direct
    pathologist or audiologist when the services are                 connection with the donation of a human organ.
    provided in a hospital, clinic or private office.                Benefits are payable for any person who donates
    Services provided in a school-based setting are                  a human organ to a person covered under the Plan,
    not covered.                                                     regardless of whether the donor is a member of




                                                                                                                                 Covered Services
                                                                                                                                 Benefit Highlights
    Covered speech-language pathology services                       the Plan.
    include the following:                                           The Plan also covers expenses for human leukocyte
    •	 The examination and remedial services for                     antigen testing or histocompatibility locus antigen
       speech defects caused by physical disorders                   testing necessary to establish the suitability of a
                                                                     bone marrow transplant donor. Such expenses
    •	 Physiotherapy in speech rehabilitation                        consist of testing for A, B or DR antigens, or any
       following laryngectomy                                        combination thereof, consistent with the guidelines,
    The Plan does not cover the following:                           criteria, rules and regulations established by the
                                                                     Massachusetts Department of Public Health.
    •	 Services that a school system must provide
       under Chapter 766 in Massachusetts or under
                                                                     Hospice Care Services
       a similar law in other states
                                                                     Upon certification or re-certification by a physician
    •	 Language therapy for learning disabilities
                                                                     that the covered individual is terminally ill, benefits
       such as dyslexia
                                                                     are payable for charges incurred for the covered
    •	 Cognitive therapy or rehabilitation                           hospice care services when the patient is enrolled
                                                                     in a Medicare-certified hospice program. The
    •	 Voice therapy
                                                                     services must be furnished under a written plan
34. Wigs are covered only for the replacement of                     of hospice care, established by a hospice and
    hair loss as a result of treatment of any form                   periodically reviewed by the medical director and
    of cancer or leukemia. The maximum benefit                       interdisciplinary team of the hospice.
    for a wig is limited to $350 per calendar year.
                                                                     A person is considered to be terminally ill when given
35. X-rays and other radiological exams.                             a medical prognosis of six (6) months or less to live.

( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
Care Program” section for specific notification requirements and responsibilities.



                                                                                                                            43
                     Description of Covered Services


                     List of Covered Hospice Care Services                                     terminally ill person. Bereavement counseling
                     The Plan covers the following hospice care services:                      must be furnished within 12 months after the
                                                                                               date of death and it must be furnished by a:
                     1. Part-time, intermittent nursing care provided
                        by or supervised by a registered nurse                                 (a)   Physician
                                                                                               (b)   Psychologist
                     2. Physical, respiratory, occupational and speech
                                                                                               (c)   Member of the clergy
                        therapy by an appropriately licensed or
                                                                                               (d)   Registered nurse, or
                        certified therapist
                                                                                               (e)   Social worker
                     3. Medical social services
                                                                                          No hospice benefits are payable for services not
                     4. Part-time, intermittent services of a home health                 included in this list, nor for any service furnished
                        aide under the direction of a registered nurse                    by a volunteer or for which no charge is
                                                                                          customarily made.
                     5. Necessary medical supplies and
                        medical appliances
                                                                                          Hospital-Based Personal Emergency
                     6. Drugs and medications prescribed by                               Response Systems (PERS)
                        a physician and charged by the hospice
                                                                                          Benefits are payable for the rental of a PERS if:
                     7. Laboratory services
                                                                                          1. The service is provided by a hospital
                     8. Physicians’ services
Benefit Highlights
Covered Services




                                                                                          2. The patient is homebound and at risk
                     9. Transportation needed to safely transport                            medically, and
                        the terminally ill person to the place where
                        that person is to receive a covered hospice                       3. The patient is alone at least four (4) hours a day,
                        care service                                                         five (5) days a week, and is functionally impaired

                     10. Psychological, social and spiritual counseling                   No benefits are payable for the purchase of
                         for the patient furnished by a:                                  a PERS unit.

                          (a)   Physician
                          (b)   Psychologist
                                                                                          ( Durable Medical Equipment (DME)
                          (c)   Member of the clergy                                      To meet the Plan’s definition of DME, the service or
                          (d)   Registered nurse, or                                      supply must be:
                          (e)   Social worker
                                                                                          1. Provided by a DME supplier
                     11. Dietary counseling furnished by
                                                                                          2. Designed primarily for therapeutic purposes
                         a registered dietitian
                                                                                             or to improve physical function
                     12. Respite care
                                                                                          3. Provided in connection with the treatment
                     13. Bereavement counseling furnished to surviving                       of disease, injury or pregnancy upon the
                         members of a terminally ill person’s immediate                      recommendation and approval of a physician
                         family or other persons specifically named by a
                                                                                          4. Able to withstand repeated use, and
                                                                                          5. Ordered by a physician



                     ( To obtain the maximum level of benefits, you must notify the Andover Service Center at (800) 442-9300. See the “Managed
                     Care Program” section for specific notification requirements and responsibilities.



                     44
Description of Covered Services


Benefits are payable if the DME service or supply               not paid for by the manufacturer, distributor or
meets the Plan’s definition of DME and is determined            provider of the drug or device, regardless of
to be medically necessary, except as described in               whether the Food and Drug Administration has
the “Exclusions” section of this Handbook.                      approved the drug or device for use in treating
                                                                the patient’s particular condition.
The Plan covers the rental of DME up to the
purchase price. If the Plan determines that the             2. Non-health care services that a patient may be
purchase cost is less than the total expected rental           required to receive as a result of participation in
charges, it may decide to purchase such equipment              the clinical trial.
for your use. If you choose to continue to rent the
                                                            3. Costs associated with managing the research of
equipment, the Plan will not cover rental charges
                                                               the clinical trial.
that exceed the purchase price.
                                                            4. Costs that would not be covered for non-
Excluded Items
                                                               investigational treatments.
No benefits are available for personal comfort items
including, but not limited to, air conditioners, air        5. Any item, service or cost that is reimbursed or
purifiers, arch supports, bed pans, blood pressure             furnished by the sponsor of the clinical trial.
monitors, commodes, corrective shoes, dehumidifiers,
                                                            6. The costs of services that are inconsistent with
dentures, elevators, exercise equipment, heating
                                                               widely accepted and established national or
pads, hot water bottles, humidifiers, shower chairs,
                                                               regional standards of care.
whirlpools or spas. These items do not qualify as




                                                                                                                       Covered Services
                                                                                                                       Benefit Highlights
covered durable medical equipment.                          7. The costs of services that are provided primarily
                                                               to meet the needs of the trial, including, but not
Important: Using preferred vendors will maximize
                                                               limited to, tests, measurements and other services
your benefits by reducing your out-of-pocket costs.
                                                               that are typically covered but are being provided
For a list of preferred vendors, see Appendix J.
                                                               at a greater frequency, intensity or duration.

Coverage for Clinical Trials for Cancer                     8. Services or costs that are not covered under
                                                               the Plan.
Clinical trials are only covered for cancer treatment.
The Plan covers patient care services provided as           Coverage for qualified clinical trials shall be subject
part of a qualified clinical trial only for the treatment   to all the other terms and conditions of the policy,
of any form of cancer. Coverage is subject to all           including, but not limited to, requiring the use
pertinent provisions of the Plan, including use of          of participating providers, provisions related to
participating providers, utilization review and             utilization review and the applicable agreement
provider payment methods. In this context, patient          between the provider and the carrier.
care service means a health care item or service            The following services for cancer treatment are
provided to an individual enrolled in a qualified           covered under this benefit:
clinical trial for cancer that is consistent with the
patient’s diagnosis, consistent with the study              1. All services that are medically necessary for
protocol for the clinical trial, and would otherwise           treatment of your condition, consistent with the
be a covered benefit under the Plan. “Patient care             study protocol of the clinical trial, and for which
service” does not include any of the following:                coverage is otherwise available under the Plan.

1. An investigational drug or device. However, a            2. The allowed cost, as determined by the Plan, of
   drug or device that has been approved for use in            an investigational drug or device that has been
   the qualified clinical trial will be a patient care         approved for use in the clinical trial for cancer
   service to the extent that the drug or device is            treatment to the extent it is not paid for by its
                                                               manufacturer, distributor or provider.


                                                                                                                  45
                Exclusions
              The Plan does not provide benefits for the following     6. A service or supply provided by you, a member
              services. Please note that charges that are excluded        of your family or by any person who resides in
              by the Plan do not count toward out-of-pocket               your home. Your family consists of you, your
              maximums, copays or deductible amounts.                     spouse and children, as well as brothers, sisters
                                                                          and parents of both you and your spouse.
              1. A service or supply furnished without the
                 recommendation and approval of a physician            7. A medical supply or service (such as a court-
                 (that is, without an order)                              ordered testing or an insurance physical)
                                                                          required by a third party that is not otherwise
              2. A service or supply reviewed under the Managed
                                                                          medically necessary. Examples of a third party
                 Care Program and determined by the Plan not
                                                                          are an employer, an insurance company,
                 to be medically necessary
                                                                          a school or a court.
              3. A service or supply that is determined by the
                                                                       8. Acne-related services, such as the removal
                 Plan to be experimental or investigational; that
                                                                          of acne cysts, injections to raise acne scars,
                 is, inadequate or lacking in evidence as to its
                                                                          cosmetic surgery, dermabrasion or other
                 effectiveness, through the use of objective
                                                                          procedures to plane the skin. Benefits are
                 methods and study over a long enough period
                                                                          provided for outpatient medical care to diagnose
                 of time to be able to assess outcomes. The fact
                                                                          or treat the underlying condition identified
                 that a physician ordered it, or that this treatment
                                                                          as causing the acne.
                 has been tried after others have failed, does not
                 make it medically necessary.                          9. Acupuncture and acupuncture-related services
              4. A service or supply that is not medically             10. Anesthesia and other services required for the
                 necessary for the care and treatment of an                performance of a service that is not covered
                 injury, disease or pregnancy, unless:                     under the Plan. Non-covered services include
                                                                           those for which there is no Plan benefit and
                   (a) Furnished by a hospital for routine care of
                                                                           those that the Plan has determined to be not
                       a newborn child during a hospital stay that
                                                                           medically necessary.
                       begins with birth and while the child’s
Exclusions
Limitations




                       mother is confined in the same hospital, or     11. Arch supports
                   (b) Furnished by a hospital or physician for        12. The amount by which a charge for blood is
                       covered preventive care, as outlined in             reduced by blood donations
                       Appendix I, or
                                                                       13. Blood pressure cuff (sphygmomanometer)
                   (c) Such service or supply qualifies as a covered
                                                                       14. Breast pumps
                       hospice care service (see page 43)
                                                                       15. Transportation in chair cars/vans
              5. A service or supply furnished for an
                 occupational injury or disease for which a            16. Any clinical research trial other than a qualified
                 person is entitled to benefits under a Workers’           clinical trial for the treatment of cancer (see
                 Compensation Law or similar law                           “Qualified Clinical Trials for Cancer” on
                                                                           page 56)




              46
Exclusions


17. Cognitive rehabilitation or therapy                  31. Presbyopia-correcting intraocular lenses (IOLs)
                                                             including, but not limited to, accommodating
18. Computer-assisted communications devices
                                                             and multifocal IOLs designed to restore a fuller
19. Custodial care                                           range of near, intermediate and far distances as
                                                             compared to monofocal IOLs. Examples include
20. Dentures or dental prostheses
                                                             Crystalens®, ReZoom® and AcrySof® ReSTOR.
21. Services related to surgery undertaken as the
                                                         32. Lift or riser chairs
    result of denture wear or to prepare for the
    fitting of new dentures                              33. Long-term maintenance care or
                                                             long-term therapy
22. Drugs not used in accordance with indications
    approved by the Food and Drug Administration         34. Certain manipulative or physical therapy
    (off-label use of a prescription drug), unless the       services, including but not limited to: paraffin
    use meets the definition of medically necessary          treatment; microwave, infrared and ultraviolet
    as determined by the Plan or the drug is                 therapies; diathermy; massage therapy;
    specifically designated as covered by the Plan           acupuncture; aerobic exercise; rolfing therapy;
                                                             Shiatsu; sports conditioning/weight training;
23. Over-the-counter drugs
                                                             craniosacral therapy; kinetic therapy; or
24. Any services or supplies furnished by, or                therapies performed in a group setting
    covered as a benefit under, a program of any
                                                         35. Massage therapy or services provided by a
    government or its subdivisions or agencies
                                                             massage therapist or neuromuscular therapist
    except for the following:
                                                         36. A medical service or supply for which a charge
    (a) A program established for its civilian
                                                             would not have been made in the absence
        employees
                                                             of medical insurance
    (b) Medicare (Title XVIII of the Social
                                                         37. Any medical services, including in vitro
        Security Act)
                                                             fertilization, in connection with the use of
    (c) Medicaid (any state medical assistance               a gestational carrier or surrogate
        program under Title XIX of the Social
                                                         38. Benefits for the diagnosis, treatment or
        Security Act)




                                                                                                                     Limitations
                                                                                                                     Exclusions
                                                             management of mental health/substance abuse
    (d) A program of hospice care                            conditions by medical (non-mental health)
                                                             providers. These benefits are covered when
25. Hearing aid batteries or ear molds
                                                             provided by mental health providers (see the
26. Hippotherapy                                             “Mental Health, Substance Abuse and
                                                             Enrollee Assistance Programs” section for
27. Incontinence supplies
                                                             coverage details).
28. Experimental treatment for infertility
                                                         39. Molding helmets and adjustable bands intended
29. Internet providers or email consultations                to mold the shape of the cranium
30. Language therapy for learning disabilities such      40. Orthodontic treatment, including treatment
    as dyslexia                                              done in preparation for surgery
                                                         41. Orthopedic/corrective shoe(s), except when the
                                                             shoe(s) attaches directly to a brace




                                                                                                                47
              Exclusions


              42. Orthopedic mattresses                               53. Sexual reassignment surgery and
                                                                          related services
              43. Oxygen equipment required for use on an
                  airplane or other means of travel                   54. Stairway lifts and stair ramps
              44. Personal comfort items that could be purchased      55. Storage of autologous blood donations or other
                  without a prescription, such as air conditioners,       bodily fluids or specimens, except when done in
                  air purifiers, bed pans, blood pressure monitors,       conjunction with use in a scheduled procedure
                  commodes, dehumidifiers, elevators, exercise            that is covered under the Plan
                  equipment, heating pads, hot water bottles,
                                                                      56. Surface electromyography (SEMG)
                  humidifiers, telephones, shower chairs,
                  televisions, whirlpools or spas and other           57. Telephone consultations
                  similar items
                                                                      58. Any type of thermal therapy device
              45. Any physical therapy services provided by
                                                                      59. Virtual colonoscopy or virtual colonography
                  athletic trainers
                                                                          (standard colonoscopy, however, is covered
              46. Private duty nursing services in an acute care          according to the Preventive Care Schedule
                  hospital or any other inpatient facility                in Appendix I)
              47. Redundant or duplicate services. A service is       60. Vision care, including:
                  considered redundant when the same service
                                                                          (a) Orthoptics or visual therapy for correction
                  or supply is being provided or being used,
                                                                              of vision
                  concurrently, to treat the condition for which
                  it is ordered.                                          (b) Radial keratotomy and related
                                                                              laser surgeries
              48. Services received at non-medical
                  religious facilities                                    (c) Other surgeries, services or supplies
                                                                              furnished in conjunction with the
              49. Reversal of voluntary sterilization
                                                                              determination or correction of refractive
              50. Sensory integration therapy                                 errors such as astigmatism, myopia,
                                                                              hyperopia and presbyopia (except as shown
              51. Any services and treatments required under law
                                                                              under Routine Eye Examinations in the
Exclusions
Limitations




                  to be provided by the school system for a child
                                                                              “Benefit Highlights” and “Description
              52. Costs associated with serious preventable                   of Covered Services” sections)
                  adverse health care events are not covered, in
                                                                      61. Voice therapy
                  accordance with Department of Public Health
                  (DPH) regulations. Massachusetts providers are      62. Worksite evaluations performed by a physical
                  not permitted to bill members for designated            therapist to evaluate a patient’s ability to return
                  serious reportable health care events. : For            to work
                  more information on this policy and a list of
                  these events, visit www.unicarestateplan.com >
                  “Members” > “Forms and Documents.”




              48
  Limitations
The Plan limits benefits for the following services                            (trauma care), reduction of swelling, pain
and products:                                                                  relief, covered non-dental surgery and
                                                                               non-dental diagnostic X-rays.
1. Ambulance used for transportation services
   other than in the case of an emergency. Please                         (b) Oral surgical procedures for non-dental
   see the definition of “Emergency” on page 53.                              medical treatment, such as the reduction of
   Benefits are payable only for transportation                               a dislocated or fractured jaw or facial bone,
   to the nearest facility equipped to treat the                              and removal or excision of benign or
   condition. Transportation required for medical                             malignant tumors, are provided to the same
   appointments, including dialysis treatment, is                             extent as other covered surgical procedures
   not covered.                                                               described on page 58.
2. Air and sea ambulance services are limited to                          (c) The following procedures when a member
   the medically necessary transfer to the nearest                            has a serious medical condition† that makes
   facility equipped to treat the condition.                                  it essential that he or she be admitted to a
                                                                              hospital as an inpatient, to a surgical day
3. Assistant surgeon services are limited to the
                                                                              care unit or to a freestanding ambulatory
   services of only one assistant surgeon per
                                                                              surgical center as an outpatient, in order for
   procedure when medically necessary. Second
                                                                              the dental care to be performed safely:
   and third assistants are not covered.
                                                                               1. Extraction of seven (7) or more teeth
    Non-physician assistants at surgery, such as
    physician assistants (PAs), nurse practitioners,                           2. Gingivectomies (including osseous
    nurses and technicians are not covered. Interns,                              surgery) of two (2) or more gum
    residents and fellows are also not covered.                                   quadrants
    Chiropractors, dentists, optometrists and
                                                                               3. Excision of radicular cysts involving
    certified midwives are not covered as surgical
                                                                                  the roots of three (3) or more teeth
    assistants or as assistant surgeons.
                                                                               4. Removal of one (1) or more
4. Cosmetic procedures/services are not covered,




                                                                                                                                 Limitations
                                                                                                                                 Exclusions
                                                                                  impacted teeth
   with the exception of the initial surgical
   procedure to correct appearance that has been                          Facility, anesthesia and related charges are only
   damaged by an accidental injury.                                       covered when the dental treatment or services
                                                                          are covered under the Plan.
5. Dental benefits are limited. The Community
   Choice Plan is a medical plan, not a dental plan.                      Dentures or dental prostheses, and the surgery
   The Plan provides benefits for covered services                        in preparation for dentures, are not covered
   relating to dental care or surgery in the                              under the Plan.
   following situations only:
    (a) Emergency treatment rendered by a dentist
        within 72 hours of an accidental injury to
        the mouth and natural sound teeth. This
        treatment is limited to the initial first aid



† Serious medical conditions include, but are not limited to, hemophilia and heart disease.


                                                                                                                            49
              Limitations


              6. Dietary or nutritional counseling or services              functions. Respite care is covered in a hospital,
                 provided by a dietitian or nutritional counselor           a skilled nursing facility, a nursing home or in
                 except for services performed by a registered              the home.
                 dietician for members with diabetes (see
                                                                        12. Retail medical clinics are limited to providing
                 page 39 for details) and hyperlipidemia
                                                                            care within the scope of their license in the state
                 (high cholesterol).
                                                                            in which they are providing services.
              7. Electrocardiograms (EKGs) are not covered
                                                                        13. Routine screening is not covered, other than the
                 when done solely for the purpose of screening
                                                                            Preventive Care Schedule outlined in Appendix I.
                 or prevention.
                                                                        14. Treatment of Temporomandibular Joint (TMJ)
              8. Eyeglasses/contact lenses are limited to the
                                                                            disorder is limited to the initial diagnostic
                 provision, replacement or fitting for the initial
                                                                            examination, initial testing and medically
                 set only when subsequent to an injury to
                                                                            necessary surgery.
                 the eye or up to six (6) months following
                 cataract surgery.                                      15. Smoking cessation services are limited.
                                                                            Counseling is covered as a component of your
              9. In Vitro Fertilization and other associated
                                                                            preventive exam. Drugs and deterrents are
                 infertility procedures, with the exception of
                                                                            subject to the Plan’s pharmacy benefit. Smoking
                 artificial insemination, are limited to a
                                                                            cessation programs are not covered.
                 maximum of five (5) attempts (see the definition
                 of “Attempt” in “Plan Definitions”).                   16. Weight loss programs are limited to the
                                                                            treatment of members whose body mass index
              10. Orthotics are limited to medically necessary
                                                                            (BMI) is 40 or more (morbidly obese) while
                  devices. Charges for test or temporary orthotics
                                                                            under the care of a physician. Any such program
                  are not covered. Charges for video tape gait
                                                                            is subject to periodic review for medical
                  analysis and diagnostic scanning are not
                                                                            necessity and progress.
                  covered. Arch supports are also not covered.
                                                                        17. Wigs are limited to the replacement of hair loss
              11. Respite care is limited to a total of five days for
                                                                            as a result of treatment of any form of cancer or
                  a hospice patient in order to relieve the family
                                                                            leukemia. The maximum benefit for a wig is
                  or the primary care person from caregiving
                                                                            limited to $350 per calendar year.
Exclusions
Limitations




              50
  Plan Definitions
Some terms used in the UniCare State Indemnity           6. Devices that are an integral part of a surgical
Plan Handbook are defined below as they relate              procedure. This includes items such as hip
to your benefits. Read these definitions carefully;         joints, skull plates and pacemakers. It does not
they will help you understand what is covered               include devices that are not directly involved in
under the Plan.                                             the surgery, such as artificial limbs, artificial
                                                            eyes or hearing aids.
“Acute Care” – A level of care required as a result of
the sudden onset or worsening of a condition that        “Assistant Surgeon” – A physician trained in the
necessitates short term, intensive medical               appropriate surgical specialty who serves as the first
treatment. Acute inpatient care must be provided at      assistant to another surgeon during a surgical
a facility licensed as an acute care hospital. See the   procedure. When medically appropriate, the service
definition for “Hospital.”                               of only one assistant per procedure is covered under
                                                         the Plan.
“Allowed Amount” – The amount UniCare
determines to be within the range of payments most       “Attempt” – The initiation of a reproductive cycle
often made to similar providers for the same service     with the expectation of implanting a fertilized ovum.
or supply. This allowed amount may not be the            The occurrence of either of the following events
same as the provider’s actual charge. Allowed            constitutes an attempt:
amounts are expressed as maximum fees in fee
                                                         •	 Commencement of drug therapy to induce
schedules, maximum daily rates, flat amounts or
                                                            ovulation, or
discounts from charges.
                                                         •	 Operative procedures for the purpose of
“Ambulatory Surgical Center” – See “Freestanding
                                                            implantation of a fertilized ovum
Ambulatory Surgical Center.”
                                                         “Autism Spectrum Disorders” – Any of the pervasive
“Ancillary Services” – The services and supplies
                                                         developmental disorders as defined by the most
that a facility ordinarily renders to its patients for
                                                         recent edition of the Diagnostic and Statistical
diagnosis or treatment during the time the patient
                                                         Manual of Mental Disorders, including autistic
is in the facility. Ancillary services include such
                                                         disorder, Asperger’s disorder and pervasive
things as:
                                                         developmental disorders not otherwise specified.
1. Use of special rooms, such as operating or
                                                         “Balance Billing” – The term used when providers
   treatment rooms
                                                         bill you for the difference between the payments
2. Tests and exams                                       made by the Plan, based on the Plan’s allowed
                                                         amount, and the full amount the provider charged.
3. Use of special equipment in the facility
                                                         The provider charges above the Plan’s allowed
4. Drugs, medications, solutions, biological             amounts will not be considered for payment by the
   preparations and medical and surgical supplies        Plan. Under Massachusetts General Law, Chapter
   used while an inpatient in the facility               32A: Section 20, providers who render services in
                                                                                                                  General Provisions
                                                                                                                  Plan Definitions



                                                         Massachusetts are prohibited from billing you for
5. Administration of infusions and transfusions.
                                                         amounts above the Plan’s allowed amounts.
   This does not include the cost of whole blood,
   packed red cells, or blood donor fees.




                                                                                                             51
                     Plan Definitions


                     “Calendar Year Deductible” – The calendar year         “Coronary Artery Disease Secondary Prevention
                     deductible is a fixed dollar amount you pay for        Program” – An approved established program for
                     certain services before the Plan begins paying         individuals with a diagnosis of coronary artery
                     benefits for you or for a covered dependent.           disease, offered by a specialized interdisciplinary
                     As mandated by the federal Mental Health Parity        team of clinicians, designed to reduce the effects
                     law, your calendar year deductible is shared between   of heart disease by lifestyle change, diet control,
                     the medical benefits portion and the out-of-network    exercise, stress reduction and group support.
                     mental health/substance abuse benefits portion
                                                                            “Cosmetic Procedures/Services” – Cosmetic services
                     of your health plan coverage.
                                                                            are those services performed mainly for the purpose
                     “Cardiac Rehabilitation Program” – A recognized,       of improving appearance. These services do not
                     multi-disciplinary program operated by a licensed      restore bodily function or correct functional
                     facility that treats cardiovascular disease through    impairment. Cosmetic services are not covered,
                     cardiac rehabilitation treatment. The program          even if they are intended to improve a member’s
                     must meet the generally accepted standards             emotional outlook or treat a member’s mental
                     of cardiac rehabilitation.                             health condition.
                     “Cardiac Rehabilitation Treatment” – Treatment         “Custodial Care” – A level of care that is chiefly
                     of documented cardiovascular disease by a              designed to assist a person in the activities of daily
                     cardiovascular rehabilitation program that includes    living and cannot reasonably be expected to greatly
                     exercise and diet management to improve                restore health or bodily function.
                     cardiovascular function.
                                                                            “Dependent”
                     “Cognitive Rehabilitation or Cognitive Therapy” –
                                                                            (a) The employee’s or retiree’s spouse or a divorced
                      Treatment to restore function or minimize effects
                                                                                spouse who is eligible for dependent coverage
                     of cognitive deficits, including but not limited to
                                                                                pursuant to Massachusetts General Laws Chapter
                     those related to thinking, learning and memory.
                                                                                32A as amended.
                     “Community Choice Hospital” – A Massachusetts
                                                                            (b) A child, stepchild, adoptive child or eligible
                     hospital designated by the Plan where certain
                                                                                foster child.
                     services are covered by the Plan at the lower
                     member copays and at no coinsurance. Such              (c) An unmarried child who upon becoming 19
                     services include inpatient admission and outpatient        years of age is mentally or physically incapable
                     surgery, among others.                                     of earning his or her own living, proof of which
                                                                                must be on file with the GIC.
                     “Complex Procedures/Neonatal ICU Care” – Select
                     inpatient surgical procedures designated by the Plan   If you have questions about coverage for someone
                     or neonatal ICU care for which significant clinical    whose relationship to you is not listed above,
                     experience is likely to enhance the quality of care.   contact the GIC.
                     The Plan has also specified certain hospitals that
                                                                            “Designated Hospital” – A hospital designated by
                     meet experience parameters in terms of patient
                                                                            the Plan for which the benefits are covered at a
                     volume for each of these procedures. For those
  Plan Definitions
General Provisions




                                                                            higher level for certain services, specifically:
                     procedures performed in the corresponding
                                                                            complex procedures, neonatal ICUs and transplants.
                     specified hospitals, services are covered at the
                     lower member copays.




                     52
Plan Definitions


“Durable Medical Equipment” – Equipment                  ulcerative colitis, gastroesophageal reflux,
designed primarily for therapeutic purposes or to        gastrointestinal motility, chronic intestinal pseudo-
extend function that can stand repeated use and is       obstruction, and inherited diseases of amino acids
medically necessary and prescribed by a physician.       and organic acids.
Such equipment includes wheelchairs, crutches,
                                                         “Experimental or Investigational Procedures” –
oxygen and respiratory equipment. Personal items
                                                         A service that is determined by the Plan to be
related to activities of daily living such as commodes
                                                         experimental or investigational; that is, inadequate
and shower chairs are not covered.
                                                         or lacking in evidence as to its effectiveness, through
“Early Intervention Services” – Medically necessary      the use of objective methods and study over a long
services that include occupational, physical and         enough period of time to be able to assess outcomes.
speech therapy, nursing care and psychological           The fact that a physician ordered it or that this
counseling for children from birth until they turn       treatment has been tried after others have failed
three years old. These services must be provided by      does not make it medically necessary.
persons licensed or certified under Massachusetts
                                                         “Family Planning Services” – Office visits and
law, who are working in Early Intervention programs
                                                         procedures for the purpose of contraception.
approved by the Department of Public Health.
                                                         Procedures include fitting for a diaphragm or
“Emergency” – An emergency is an illness or              cervical cap; the insertion, re-insertion, or removal
medical condition, whether physical or mental, that      of an IUD or Levonorgestrel (Norplant); and the
manifests itself by symptoms of sufficient severity,     injection of progesterone (Depo-Provera). FDA-
including severe pain that the absence of immediate      approved contraceptive drugs and devices are
medical attention could reasonably be expected by        available through your prescription drug plan.
a prudent layperson, who possesses an average
                                                         “Freestanding Ambulatory Surgical Center” –
knowledge of health and medicine, to result in
                                                         An appropriately licensed facility that is
serious jeopardy to physical and/or mental health,
                                                         geographically independent of any other health care
serious impairment to bodily functions, serious
                                                         facility, that operates autonomously and functions
dysfunction of any bodily organ or part, or, in the
                                                         exclusively for the purpose of providing outpatient
case of pregnancy, a threat to the safety of a member
                                                         same-day surgical, diagnostic, and medical services
or her unborn child. Emergency treatment does not
                                                         requiring a dedicated operating room and a
include urgent care. Emergency treatment may
                                                         postoperative recovery room.
be rendered in a hospital, in a physician’s office or
in another medical facility.                             “High-Tech Imaging Services” – Tests that vary from
                                                         plain film X-rays by offering providers a more
“Enrollee” – An employee, retiree or survivor
                                                         comprehensive view of the human body. Many of
covered by the GIC’s health benefits program who
                                                         these tests also subject members to significantly
is enrolled in the Plan.
                                                         higher levels of radiation compared to plain film
“Enteral Therapy” – Prescribed nutrition that is         X-rays and are also much more expensive. These
administered through a tube that has been inserted       procedures include but are not limited to MRIs,
into the stomach or intestines. Enteral formulas are     CT scans and PET scans.
                                                                                                                      General Provisions
                                                                                                                      Plan Definitions


not covered under the Plan. Prescription and
nonprescription enteral formulas are covered under
the prescription drug plan only when ordered by a
physician for the medically necessary treatment of
malabsorption disorders caused by Crohn’s disease,




                                                                                                                 53
                     Plan Definitions


                     “Home Health Care” – Health services and supplies       The term “Hospital” includes freestanding
                     provided by a home health care agency on a part-        ambulatory surgical centers operating pursuant
                     time, intermittent or visiting basis. Such services     to law.
                     and supplies must be provided in a person’s place of
                                                                             The term “Hospital” does not include:
                     residence (not an institution) while the person is
                     confined as a result of injury, disease or pregnancy.   (a) Rest homes
                     To be considered for coverage, home health care
                                                                             (b) Nursing homes
                     must be delivered by a home health care agency
                     certified by Medicare.                                  (c) Convalescent homes
                     “Home Health Care Plan” – A plan of care for            (d) Places for custodial care
                     services in the home ordered in writing by a
                                                                             (e) Homes for the aged
                     physician. A home health care plan is subject to
                     review and approval by the Plan.                        Also see the definitions for “Community Choice
                                                                             Hospitals” and “Other Inpatient Facilities.”
                     “Home Infusion Company” – A company that is
                     licensed as a pharmacy and is qualified to provide      “Hospital Stay” – The time a person is confined
                     home infusion therapy.                                  to a hospital and incurs a room and board charge
                                                                             for inpatient care other than custodial care.
                     “Home Infusion Therapy” – The administration of
                     intravenous, subcutaneous or intramuscular              “Incurred Date” – The date a service or supply
                     therapies provided in the home setting.                 is provided.
                     Subcutaneous and intramuscular drugs are available
                                                                             “Infertility” – The condition of a healthy individual
                     through your prescription drug plan.
                                                                             who is unable to conceive or produce conception:
                     “Hospice” – A public agency or a private
                                                                             (a) During a period of one year if the female is age
                     organization that provides care and services for
                                                                                 35 or younger, except if this condition is the
                     terminally ill persons and their families and is
                                                                                 result of a voluntary sterilization or the normally
                     certified as such by Medicare.
                                                                                 occurring aging process.
                     “Hospital” – An institution that meets all of the
                                                                             (b) During a period of six months if the female is
                     following conditions:
                                                                                 over the age of 35, except if this condition is the
                     1. Is operated pursuant to law for the provision            result of voluntary sterilization or the normally
                        of medical care                                          occurring aging process.
                     2. Provides continuous 24-hour-a-day nursing care       If an individual conceives but is unable to carry that
                                                                             pregnancy to live birth, the period of time she
                     3. Has facilities for diagnosis
                                                                             attempted to conceive prior to achieving that
                     4. Has facilities for major surgery                     pregnancy will be included in the calculation of the
                                                                             one-year or six-month period, as applicable.
                     5. Provides acute medical/surgical care or acute
                        rehabilitation care                                  “Injury” – Bodily injury sustained accidentally by
  Plan Definitions
General Provisions




                                                                             external means.
                     6. Is licensed as an acute hospital, and
                     7. Has an average length of stay of less than
                        25 days




                     54
Plan Definitions


“Manipulative Therapy” – Hands-on treatment             “Member” – An enrollee or his/her dependent who
provided by a chiropractor, osteopath or physician      is enrolled in the Plan.
by means of direct manipulation or movement
                                                        “Member Care Specialist” – A specially-trained
to relieve pain, restore function and/or minimize
                                                        customer service representative who assists
disability as a result of disease or injury to the
                                                        members by responding to health plan questions
neuromuscular and/or musculoskeletal system.
                                                        and concerns; identifying and choosing appropriate
See Exclusion 34 in the “Exclusions” section
                                                        health care providers; and providing guidance to
for examples of manipulative therapies that are
                                                        health care resources and support.
not covered.
                                                        “Non-Experimental Infertility Procedure” –
“Medically Necessary” – With respect to care under
                                                        A procedure recognized as generally accepted and/
the Plan, the treatment will meet at least the
                                                        or non-experimental by the American Fertility
following standards:
                                                        Society and the American College of Obstetrics
1. Is adequate and essential for evaluation or          and Gynecology.
   treatment consistent with the symptoms, proper
                                                        “Nursing Home” – An institution that:
   diagnosis and treatment appropriate for the
   specific member’s illness, disease or condition      1. Provides inpatient skilled nursing care and
   as defined by standard diagnostic nomenclatures         related services, and
   (DSM-IV or its equivalent ICD-9CM)
                                                        2. Is licensed in any jurisdiction requiring such
2. Is reasonably expected to improve or palliate           licensing, but
   the member’s illness, condition or level
                                                        3. Does not qualify as a skilled nursing facility
   of functioning
                                                           (SNF) as defined by Medicare
3. Is safe and effective according to nationally
                                                        A home, facility or part of a facility does not qualify
   accepted standard clinical evidence generally
                                                        as a skilled nursing facility or nursing home if it is
   recognized by medical professionals and
                                                        used primarily for:
   peer-reviewed publications
                                                        1.   Rest
4. Is the most appropriate and cost-effective level
                                                        2.   The care of drug abuse or alcoholism
   of care that can safely be provided for the
                                                        3.   The care of mental diseases or disorders
   specific member’s diagnosed condition, and
                                                        4.   Custodial or educational care
5. Is based on scientific evidence for services and
                                                        “Occupational Injury/Disease” – An injury or
   interventions that are not in widespread use
                                                        disease that arises out of and in the course of
Note: The fact that a physician may prescribe, order,   employment for wage or profit (see the
recommend or approve a procedure, treatment,            “Exclusions” section).
facility, supply, device or drug does not, in and of
                                                        “Occupational Therapy” – Occupational therapy is
itself, make it medically necessary or make the
                                                        skilled treatment that helps individuals achieve
charge a covered expense under the Plan, even if
                                                        independence with activities of daily living after an
it has not been listed as an exclusion.
                                                                                                                   General Provisions
                                                                                                                   Plan Definitions


                                                        illness or injury not incurred during the course of
“Medical Supplies or Equipment” – Disposable            employment. Services include: treatment programs
items prescribed by physicians as medically             aimed at improving the ability to carry out activities
necessary to treat disease and injury. Such items       of daily living; comprehensive evaluations of the
include surgical dressings, splints and braces.         home; and recommendations and training in the
                                                        use of adaptive equipment to replace lost function.




                                                                                                              55
                     Plan Definitions


                     “Off-Label Use of a Prescription Drug” – The use          “Physician Tiering” – A program implemented by
                     of a drug that does not meet the prescribed               the Plan as part of the GIC’s Clinical Performance
                     indications as approved by the Food and Drug              Improvement (CPI) Initiative, whereby Massachusetts
                     Administration (FDA).                                     physicians are assigned to different tiers based on
                                                                               an extensive evaluation of both their quality and
                     “Orthotic” – An orthopedic appliance or apparatus
                                                                               cost efficiency.
                     used to support, align or correct deformities and/or
                     to improve the function of movable parts of the           “Preferred Vendor” – A provider contracted by the
                     body. An orthotic must be ordered by a physician,         Plan to provide certain services or equipment,
                     be custom fabricated (molded and fitted) to the           including but not limited to durable medical
                     patient’s body, and be for use by that patient only.      equipment or medical supplies. When you use
                                                                               preferred vendors, you receive these services at a
                     “Other Inpatient Facilities” – Includes the following
                                                                               higher benefit level than when you use other
                     hospitals/facilities:
                                                                               providers for these services.
                     1. Skilled nursing facilities
                                                                               “Prostheses” – Items that replace all or part of
                     2. Chronic disease hospitals/facilities                   a bodily organ or limb and that are medically
                                                                               necessary and are prescribed by a physician.
                     3. Transitional care hospitals/facilities
                                                                               Examples include breast prostheses and
                     4. Sub-acute care hospitals/facilities                    artificial limbs.
                     5. Long-term care hospitals/facilities                    “Qualified Clinical Trials for Cancer” – Clinical
                                                                               trials that, according to state law, meet all of the
                     6. Any inpatient facility with an average length
                                                                               following conditions:
                        of stay greater than 25 days
                                                                               1. The clinical trial is to treat cancer.
                     “Physical Therapy” – Hands-on treatment provided
                     by a licensed physical therapist by means of direct       2. The clinical trial has been peer reviewed and
                     manipulation, exercise, movement or other physical           approved by one of the following:
                     modalities to relive pain, restore function and/or
                                                                                   − United States National Institutes of Health
                     minimize disability as a result of disease or injury to
                     the neuromuscular and/or musculoskeletal system               − A cooperative group or center of the National
                     or following the loss of a body part. For examples of           Institutes of Health
                     non-covered physical therapy services, see Exclusion
                                                                                   − A qualified non-governmental research entity
                     34 in the “Exclusions” section.
                                                                                     identified in guidelines issued by the National
                     “Physician” – The term “physician” includes the                 Institutes of Health for center support grants
                     following health care providers acting within the
                                                                                   − The United States Food and Drug
                     scope of their licenses or certifications:
                                                                                     Administration pursuant to an investigational
                     1.   Physician                                                  new drug exemption
                     2.   Certified nurse midwife
                                                                                   − The United States Departments of Defense
                     3.   Chiropractor
  Plan Definitions
General Provisions




                                                                                     or Veterans Affairs
                     4.   Dentist
                     5.   Nurse practitioner                                       − With respect to Phase II, III and IV
                     6.   Optometrist                                                clinical trials only, a qualified institutional
                     7.   Podiatrist                                                 review board




                     56
Plan Definitions


3. The facility and personnel conducting the               “Reconstructive and Restorative Surgery” – Surgery
   clinical trial are capable of doing so by virtue        intended to improve or restore bodily function or to
   of their experience and training and treat              correct a functional physical impairment that has
   a sufficient volume of patients to maintain             been caused by one of the following:
   that experience.
                                                           •	 A congenital anomaly, or
4. With respect to Phase I clinical trials, the facility   •	 A previous surgical procedure or disease
   shall be an academic medical center or an
                                                           Restoration of a bodily organ that is surgically
   affiliated facility and the clinicians conducting
                                                           removed during treatment of cancer must be
   the trial shall have staff privileges at said
                                                           performed within five (5) years of surgical removal.
   academic medical center.
                                                           “Rescission” – A retroactive termination of coverage
5. The patient meets the patient selection
                                                           as a result of fraud or an intentional misrepresentation
   criteria enunciated in the study protocol
                                                           of material fact. A cancellation or discontinuance
   for participation in the clinical trial.
                                                           of coverage is not a rescission if the cancellation
6. The patient has provided informed consent               has a prospective effect or if the cancellation is due
   for participation in the clinical trial in              to a failure to timely pay required premiums or
   a manner that is consistent with current legal          contributions toward the cost of coverage.
   and ethical standards.
                                                           “Respite Care” – Services rendered to a hospice
7. The available clinical or pre-clinical data provide     patient to relieve the family or primary care person
   a reasonable expectation that the patient’s             from caregiving functions.
   participation in the clinical trial will provide
                                                           “Retail Medical Clinics” – Licensed medical clinics
   a medical benefit that is commensurate with
                                                           located at certain pharmacies that provide services
   the risks of participation in the clinical trial.
                                                           by nurse practitioners or physician assistants for
8. The clinical trial does not unjustifiably duplicate     basic primary medical services. These services are
   existing studies.                                       limited to episodic, urgent care such as treatment
                                                           for an earache or sinus infection. Retail medical
9. The clinical trial must have a therapeutic intent
                                                           clinics are limited to providing care within the scope
   and must, to some extent, assume the effect
                                                           of their license in the state in which they are
   of the intervention on the patient.
                                                           providing services.
Coverage for qualified clinical trials shall be subject
                                                           “Skilled Care” – Medical services that can only be
to all the other terms and conditions of the policy,
                                                           provided by a registered or certified professional
including, but not limited to, requiring the use
                                                           health care provider.
of participating providers, provisions related to
utilization review and the applicable agreement
between the provider and the carrier.
                                                                                                                      General Provisions
                                                                                                                      Plan Definitions




                                                                                                                 57
                     Plan Definitions


                     “Skilled Nursing Facility (SNF)” – An institution that:   6. Electrocauterization
                     1. Is operated pursuant to law                            7. Diagnostic and therapeutic endoscopic procedures
                     2. Is licensed or accredited as a skilled nursing         8. Injection treatment of hemorrhoids and
                        facility if the laws of the jurisdiction in which         varicose veins
                        it is located provide for the licensing or the
                                                                               9. An operation by means of laser beam
                        accreditation of a skilled nursing facility
                                                                               “Temporomandibular Joint (TMJ) Disorder” –
                     3. Is approved as a skilled nursing facility for
                                                                               A syndrome or dysfunction of the joint between
                        payment of Medicare benefits or is qualified
                                                                               the jawbone and skull and the muscles, nerves
                        to receive such approval, if requested
                                                                               and other tissues related to that joint.
                     4. Is primarily engaged in providing room and
                                                                               “Terminal Illness” – An illness that, if it runs its
                        board and skilled nursing care under the
                                                                               course, is associated with a life expectancy of six
                        supervision of a physician
                                                                               months or less.
                     5. Provides continuous 24-hour-a-day skilled
                                                                               “Tiers” – Different levels into which the Plan groups
                        nursing care by or under the supervision
                                                                               physicians based upon an evaluation of certain
                        of a registered nurse (RN), and
                                                                               quality measures and how efficiently they use
                     6. Maintains a daily medical record of each patient       their resources.
                     A home, facility or part of a facility does not qualify   “Travel Access Providers” – UniCare providers that
                     as a skilled nursing facility or nursing home if it is    are available to members when traveling outside
                     used primarily for:                                       their home state. When you use these providers,
                                                                               you are not balance billed for your care.
                     1.   Rest
                     2.   The care of mental diseases or disorders             “Urgent Care” – Treatment that is provided as soon
                     3.   The care of drug abuse or alcoholism, or             as the treatment can be arranged, but the treatment
                     4.   Custodial or educational care                        is not immediately necessary to prevent death
                                                                               or permanent impairment. Urgent care does not
                     “Spouse” – The legal spouse of the covered
                                                                               qualify as emergency treatment.
                     employee or retiree.
                                                                               “Visiting Nurse Association” – An agency certified
                     “Surgical Procedure” – Any of the following types
                                                                               by Medicare that provides part-time, intermittent
                     of treatment:
                                                                               skilled nursing services and other home care
                     1. A cutting procedure                                    services in a person’s place of residence and is
                                                                               licensed in any jurisdiction requiring such licensing.
                     2. The suturing of a wound
                                                                               “Written Proof” – Satisfactory proof, in writing, of
                     3. The treatment of a fracture
                                                                               the incurral of a claim.
                     4. The reduction of a dislocation
                     5. Radiotherapy, excluding radioactive isotope
  Plan Definitions
General Provisions




                        therapy, if used in lieu of a cutting operation
                        for removal of a tumor




                     58
  General Provisions
This section describes the enrollment process for        When Coverage Begins
you and your eligible dependent(s); when coverage
begins and ends; and continuing coverage when            Coverage under the Plan starts as follows:
eligibility status changes.                              For new employees: Coverage begins on the first of
                                                         the month following 60 days or two calendar
Free or Low-Cost Health Coverage                         months of employment, whichever is less.
to Children and Families                                 For persons applying during an annual enrollment
If you are eligible for health coverage from your        period: Coverage begins on the following July 1.
employer, but are unable to afford the premiums,         For dependents: Coverage begins on the later of:
some states have premium assistance programs that
can help pay for coverage. These states use funds        1. The date your own coverage begins, or
from their Medicaid or CHIP programs to help             2. The date on which the GIC has determined your
people who are eligible for employer-sponsored              dependent is eligible and qualifies as a dependent
health coverage, but need assistance in paying their
health premiums. For more information, see               For new retirees, spouses and surviving spouses:
Appendix G, “Federal and State Mandates,” at the         You will be notified by the GIC of the date on which
back of this Handbook.                                   coverage begins.

Application for Coverage                                 Continued Coverage
You must apply to the GIC for enrollment in the          Your eligibility for these benefits continues if
Plan. To obtain the appropriate forms, active            you are:
employees should contact their GIC Coordinator,          1. An employee of the Commonwealth, a
and retirees should contact the GIC.                        municipality or other entity that participates
To enroll newborns: You must enroll a child within          in the GIC
31 days of the child’s birth. Active employees should    2. A retiree of the Commonwealth, a municipality
see their GIC Coordinator to add the child to their         or other entity that participates in the GIC
health insurance coverage. Retirees must submit a           who is not eligible for Medicare
written request for coverage to the GIC and include
a copy of the child’s birth certificate.                 3. A surviving spouse who is not eligible
                                                            for Medicare
To enroll or add your dependent(s): You must enroll
each additional dependent when he or she becomes         4. A retiree with Medicare who is not eligible
eligible. If you marry, you must enroll your spouse         for the UniCare State Indemnity Plan/
within 31 days of the marriage.                             Medicare Extension

To enroll adopted children: Adopted children must        5. The spouse of a retiree of the Commonwealth,
                                                                                                                  General Provisions
                                                                                                                  Plan Definitions



be enrolled within 31 days of placement in the              a municipality or other entity that participates
home. Send a written request to the GIC along with          in the GIC who is enrolled in Medicare Parts A
a letter from the adoption agency that states the date      and B, but you are not eligible for Parts A and
the child was placed in the home.                           B in your own right




                                                                                                             59
                     General Provisions


                     When Coverage Ends for Enrollees                     Duplicate Coverage
                     Your coverage ends on the earliest of:               No person can be covered by any other GIC health
                                                                          plan at the same time as:
                     1. The end of the month covered by the last
                        contribution toward the cost of your coverage     1. Both an employee, retiree or surviving spouse
                                                                             and a dependent, or
                     2. The end of the month in which you cease
                        to be eligible for coverage                       2. A dependent of more than one covered person
                                                                             (employee, retiree, spouse or surviving spouse)
                     3. The date the enrollment period ends
                     4. The date of death                                 Special Enrollment Condition
                     5. The date the survivor remarries, or               If you have declined the Plan for your spouse or for
                     6. The date the Plan terminates                      your dependent(s) because they have other health
                                                                          coverage, you may be able to enroll them during the
                                                                          Plan year if the other coverage is lost. To obtain the
                     When Coverage Ends for Dependents                    appropriate enrollment forms:
                     A dependent’s coverage ends on the earliest of:
                                                                          •	 Active enrollees: Contact your GIC Coordinator
                     1. The date your coverage under the Plan ends        •	 Retirees: Contact the GIC in writing
                     2. The end of the month covered by your last
                        contribution toward the cost of such coverage     Continuing Coverage
                     3. The date you become ineligible to have            The following provisions in this section explain how
                        dependents covered                                coverage may be continued or converted if eligibility
                                                                          status changes.
                     4. The date the enrollment period ends
                                                                          Continuing Health Coverage Due to
                     5. The date the dependent ceases to qualify          Involuntary Layoff
                        as a dependent                                    If you are no longer eligible for coverage due to
                     6. The date the dependent child, who is              involuntary layoff, you may have coverage under
                        permanently and totally disabled and became       the Plan continued for 39 consecutive weeks.
                        so by age 19, married and is no longer eligible   This coverage would apply to you and all of your
                        for coverage as an IRS or non-IRS dependent       dependent(s) who are covered under the Plan
                                                                          at the time you are laid off.
                     7. The date the divorced spouse remarries (or
                        the date the enrollee marries, depending on       In the event of involuntary layoff, the person who
                        the divorce decree)                               has the option to continue coverage must:

                     8. The date of the dependent’s death, or             1. Elect to continue, in writing, within 30 days after
                                                                             the date eligibility for coverage ends, and
                     9. The date the Plan terminates
                                                                          2. Pay the full cost of the coverage to the GIC
  Plan Definitions
General Provisions




                     60
General Provisions


Coverage will end on the earliest of:                  Continuing Health Coverage for Survivors
                                                       Surviving spouses of covered employees or retirees
1. The end of the month of 39 consecutive weeks
                                                       and/or their eligible dependent children may be
   following the date you cease to be eligible
                                                       able to continue coverage under this health care
   for coverage
                                                       program. Surviving spouse coverage ends upon
2. The end of the month covered by the last            remarriage. Orphan coverage is also available for
   contribution toward the cost of your coverage       some surviving dependents. For more information
                                                       on eligibility for survivors or orphans, contact
3. The date the coverage ends
                                                       the GIC.
4. The date the Plan terminates, or
                                                       To continue coverage, the person who has the option
5. In the case of a dependent, the date that           to continue coverage must:
   dependent would cease to qualify as a dependent
                                                       1. Elect to continue coverage, in writing, within
   if you had remained eligible for the coverage
                                                          30 days after the date of your death, and
Option to Continue Coverage as
                                                       2. Make the required contribution toward the cost
a Deferred Retiree                                        of the coverage
You are eligible for deferred retirement if you:
                                                       Coverage for survivors will end on the earliest of
1. Have 10 or more years of full-time service (as
                                                       these dates:
   determined by the State Retirement Board
   or a public retirement system), and                 1. The end of the month in which the survivor dies

2. Are eligible for a pension from the State           2. The end of the month covered by the last
   Retirement Board or a public retirement system         contribution payment for the coverage
   that participates with the GIC, and
                                                       3. The date the coverage ends
3. Are leaving your retirement monies in a public
                                                       4. The date the Plan terminates
   retirement system
                                                       5. In the case of a dependent, the date that
The person who chooses to continue health coverage
                                                          dependent would cease to qualify as a
as a deferred retiree must:
                                                          dependent, or
1. Contact the GIC for enrollment information,
                                                       6. The date the survivor remarries
   and
                                                       Option to Continue Coverage for Dependents
2. Pay the full cost of the coverage to the GIC
                                                       Age 26 and Over
Coverage will end on the earliest of:                  A full-time student at an accredited educational
                                                       institution at age 26 or over may elect to continue
1. The end of the month covered by the last
                                                       GIC coverage as an individual member under the
   contribution toward the cost of your coverage
                                                       Plan and pay 100 percent of the individual monthly
2. The date the coverage ends                          premium. That student must file a written
                                                                                                                 General Provisions
                                                                                                                 Plan Definitions


                                                       application with the GIC and that application must
3. The date the Plan terminates
                                                       be approved by the GIC. Full-time students age 26
4. In the case of a dependent, the date that           and over are not eligible for continued coverage
   dependent would cease to qualify as a dependent     if there has been a two-year break in the student’s
   if you had remained eligible for the coverage, or   GIC coverage.
5. The date you withdraw your monies from the
   retirement system


                                                                                                            61
                     General Provisions


                     Option to Continue Coverage after a Change               Group Health Continuation Coverage
                     in Marital Status                                        under COBRA Election Notice
                     Your spouse will not cease to qualify as a dependent
                     solely because a judgment of divorce or of separate      This subsection contains important information
                     support is granted. If that judgment is granted          about your rights to continue group health coverage
                     while the former spouse is covered as a dependent        at COBRA group rates if your group coverage
                     and states that coverage for the former spouse will      otherwise would end due to certain life events.
                     continue, that person will continue to qualify as a      Please read it carefully.
                     dependent under the Plan, provided family coverage       You will receive a COBRA notice and application
                     continues, neither party remarries and is eligible for   if the Group Insurance Commission (GIC) is
                     coverage in accordance with Massachusetts General        informed that your current GIC coverage is ending
                     Laws Chapter 32A as amended.                             due either to (1) end of employment, (2) reduction
                     If you get divorced, you must notify the GIC and         in hours of employment, (3) death of employee/
                     send them a copy of your divorce decree. If you or       retiree, (4) divorce or legal separation, or (5) loss
                     your former spouse remarry, you must also notify         of dependent child status. This COBRA notice
                     the GIC.                                                 contains important information about your right to
                                                                              temporarily continue your health care coverage in
                     The former spouse will no longer qualify as a            the Group Insurance Commission’s (GIC’s) health
                     dependent after the earliest of these dates:             plan through a federal law known as COBRA. If you
                     1. The end of the period specified in the judgment       elect to continue your coverage, COBRA coverage
                        during which that person must remain eligible         will begin on the first day of the month immediately
                        for coverage                                          after your current GIC coverage ends.

                     2. The end of the month covered by the last              You must complete the GIC COBRA Election Form
                        contribution toward the cost of the coverage          and return it to the GIC by no later than 60 days
                                                                              after your group coverage ends by sending it by mail
                     3. The date that person remarries                        to the Public Information Unit at the GIC at
                     4. The date you remarry. If that person is still         P.O. Box 8747, Boston, MA 02114 or by hand
                        covered as a dependent on this date, and the          delivery to the GIC, 19 Staniford Street, 4th floor,
                        judgment gives that person the right to continue      Boston, MA 02114. If you do not submit a
                        coverage at full cost after you remarry, then         completed election form by this deadline, you
                        that person may either elect to:                      will lose your right to elect COBRA coverage.

                          (a) Remain covered separately for the benefits      What is COBRA Coverage?
                              for which he or she was covered on that date    COBRA is a federal law under which certain former
                                                                              employees, retirees, spouses, former spouses and
                          (b) Enroll in COBRA coverage, or
                                                                              dependent children have the right to temporarily
                          (c) Have a converted policy issued to provide       continue their existing group health coverage at
                              those benefits                                  group rates when group coverage otherwise would
                                                                              end due to certain life events, called “qualifying
  Plan Definitions
General Provisions




                     For the purposes of this provision, “judgment”
                                                                              events.” If you elect COBRA coverage, you are
                     means only a judgment of absolute divorce or of
                                                                              entitled to the same coverage being provided under
                     separate support.
                                                                              the GIC’s plan to similarly situated employees or
                                                                              dependents. The GIC administers COBRA coverage.




                     62
General Provisions


This notice explains your COBRA rights and what        If you have dependent children who are covered by
you need to do to protect your right to receive it.    the GIC’s health benefits program, each child has
If you have questions about COBRA coverage,            the right to elect COBRA coverage if he or she loses
contact the GIC’s Public Information Unit at           GIC health coverage for any of the following reasons
(617) 727-2310, ext. 1 or write to the Unit at         (known as “qualifying events”):
P.O. Box 8747, Boston, MA 02114. You may also
                                                       •	 The employee-parent dies;
contact the U.S. Department of Labor’s Employee
Benefits Security Administration’s website at          •	 The employee-parent’s employment is terminated
www.dol.gov/ebsa.                                         (for reasons other than gross misconduct) or the
                                                          parent’s hours or employment are reduced;
Who is Eligible for COBRA Coverage?
Each individual entitled to COBRA (known as a          •	 The parents legally separate or divorce; or
“qualified beneficiary”) has an independent right
                                                       •	 The dependent ceases to be a dependent child
to elect the coverage, regardless of whether or not
                                                          under GIC eligibility rules.
other eligible family members elect it. Qualified
beneficiaries may elect to continue their group        How Long Does COBRA Coverage Last?
coverage that otherwise would end due to the           By law, COBRA coverage must begin on the day
following life events:                                 immediately after your group health coverage
                                                       otherwise would end. If your group coverage ends
If you are an employee of the Commonwealth of
                                                       due to employment termination or reduction in
Massachusetts or municipality covered by the
                                                       employment hours, COBRA coverage may last for
GIC’s health benefits program, you have the right
                                                       up to 18 months. If it ends due to any other
to choose COBRA coverage if:
                                                       qualifying events listed above, you may maintain
•	 You lose your group health coverage because your    COBRA coverage for up to 36 months.
   hours of employment are reduced; or
                                                       If you have COBRA coverage due to employment
•	 Your employment ends for reasons other than         termination or reduction in hours, your family
   gross misconduct.                                   members’ COBRA coverage may be extended
                                                       beyond the initial 18-month period up to a total of
If you are the spouse of an employee covered by the
                                                       36 months (as measured from the initial qualifying
GIC’s health benefits program, you have the right
                                                       event) if a second qualifying event – the insured’s
to choose COBRA coverage for yourself if you lose
                                                       death or divorce – occurs during the 18 months of
GIC health coverage for any of the following reasons
                                                       COBRA coverage. You must notify the GIC in
(known as “qualifying events”):
                                                       writing within 60 days of the second qualifying
•	 Your spouse dies;                                   event and before the 18-month COBRA period ends
                                                       in order to extend the coverage. Your COBRA
•	 Your spouse’s employment with the Commonwealth
                                                       coverage may be extended to a total of 29 months
   or participating municipality ends for any reason
                                                       (as measured from the initial qualifying event) if
   other than gross misconduct or his/her hours of
                                                       any qualified beneficiary in your family receiving
   employment are reduced; or
                                                       COBRA coverage is disabled during the first 60 days
                                                                                                               General Provisions
                                                                                                               Plan Definitions


•	 You and your spouse legally separate or divorce.    of your 18-month COBRA coverage. You must
                                                       provide the GIC with a copy of the Social Security
                                                       Administration’s disability determination within
                                                       60 days after you receive it and before your initial
                                                       18-month COBRA period ends in order to extend
                                                       the coverage.




                                                                                                          63
                     General Provisions


                     COBRA coverage will end before the maximum                you the right to purchase individual health
                     coverage period ends if any of the following occurs:      insurance policies that do not impose such pre-
                                                                               existing condition exclusions. You also have special
                     •	 The COBRA cost is not paid in full when due
                                                                               enrollment rights under federal law, including the
                        (see section on paying for COBRA);
                                                                               right to request special enrollment in another group
                     •	 You or another qualified beneficiary become            health plan for which you are otherwise eligible
                        covered under another group health plan that does      (such as a spouse’s plan) within 30 days after your
                        not impose any pre-existing condition exclusion        COBRA coverage ends.
                        for the qualified beneficiary’s pre-existing covered
                                                                               How Much Does COBRA Coverage Cost?
                        condition covered by COBRA benefits;
                                                                               Under COBRA, you must pay 102% of the
                     •	 You are no longer disabled as determined by            applicable cost of your COBRA coverage. If your
                        the Social Security Administration (if your            COBRA coverage is extended to 29 months due to
                        COBRA coverage was extended to 29 months               disability, your cost will increase to 150% of the
                        due to disability);                                    applicable full cost rate for the additional 11 months
                                                                               of coverage. COBRA costs will change periodically.
                     •	 The Commonwealth of Massachusetts or your
                        municipal employer no longer provides group            How and When Do I Pay for COBRA Coverage?
                        health coverage to any of its employees; or            If you elect COBRA coverage, you must make your
                     •	 Any reason for which the GIC terminates a              first payment for COBRA coverage within 45 days
                        non-COBRA enrollee’s coverage (such as fraud).         after the date you elect it. If you do not make your
                                                                               first payment for COBRA coverage within the 45-day
                     The GIC will notify you in writing if your COBRA          period, you will lose all COBRA coverage rights
                     coverage is to be terminated before the maximum           under the plan.
                     coverage period ends. The GIC reserves the right
                     to terminate your COBRA coverage retroactively if         Your first payment must cover the cost of COBRA
                     you are subsequently found to have been ineligible        coverage from the time your coverage would have
                     for coverage.                                             ended up to the time you make the first payment.
                                                                               Services cannot be covered until the GIC receives
                     How and When Do I Elect COBRA Coverage?                   and processes this first payment, and you are
                     Qualified beneficiaries must elect COBRA coverage         responsible for making sure that the amount of
                     within 60 days of the date that their group coverage      your first payment is enough to cover this entire
                     otherwise would end or within 60 days of receiving        period. After you make your first payment, you will
                     a COBRA notice, whichever is later. A qualified           be required to pay for COBRA coverage for each
                     beneficiary may change a prior rejection of COBRA         subsequent month of coverage. These periodic
                     election any time until that date. If you do not elect    payments are due usually around the 15th of each
                     COBRA coverage within the 60-day election period,         month. The GIC will send monthly bills, specifying
                     you will lose all rights to COBRA coverage.               the due date for payment and the address to which
                                                                               payment is to be sent for COBRA coverage, but you
                     There are several considerations when deciding
                                                                               are responsible for paying for the coverage even if
                     whether to elect COBRA coverage. COBRA coverage
                                                                               you do not receive a monthly statement. Payments
  Plan Definitions
General Provisions




                     can help you avoid incurring a coverage gap of more
                                                                               should be sent to the GIC’s address on the bill.
                     than 63 days, which under federal law can cause you
                     to lose your right to be exempt from pre-existing         After the first payment, you will have a 30-day grace
                     condition exclusions when you elect subsequent            period beyond the due date on each monthly bill in
                     health plan coverage. If you have COBRA coverage          which to make your monthly payment. Your COBRA
                     for the maximum period available to you, it provides      coverage will be provided for each coverage period




                     64
General Provisions


as long as payment for that coverage period is made      •	 You must inform the GIC within 60 days of the
before the end of the grace period for that payment.        later of either (1) the date of any of the following,
If you fail to make a periodic payment before the           or (2) the date on which coverage would be lost
end of the grace period for that payment, you will          because of any of the following events:
lose all rights to COBRA coverage.
                                                           − The employee’s job terminates or his/her
Can I Elect Other Health Coverage                            hours are reduced;
Besides COBRA?                                             − The insured dies;
Yes. You have the right to enroll, within 31 days
after coverage ends, in an individual health               − The insured becomes legally separated
insurance “conversion” policy with your current              or divorced;
health plan without providing proof of insurability.       − The insured or insured’s former spouse remarries;
Alternately, if you are a Massachusetts resident,
you may purchase health insurance through the              − A covered child ceases to be a dependent under
Commonwealth’s Health Connector Authority. The               GIC eligibility rules;
GIC has no involvement in conversion or Health             − The Social Security Administration determines
Connector programs, and you pay premium to the               that the employee or a covered family member
plan sponsor for the coverage. The benefits provided         is disabled; or
under such a policy might not be identical to those
provided through COBRA. You may exercise this              − The Social Security Administration determines
right in lieu of electing COBRA coverage, or you             that the employee or a covered family member
may exercise this right after you have received the          is no longer disabled.
maximum COBRA coverage available to you.                 If you do not inform the GIC of these events within the
Your COBRA Coverage Responsibilities                     time period specified above, you will lose all rights to
•	 You must inform the GIC of any address changes        COBRA coverage. To notify the GIC of any of the above
   to preserve your COBRA rights.                        events within the 60 days for providing notice, send
                                                         a letter to the Public Information Unit at Group
•	 You must elect COBRA within 60 days from the          Insurance Commission, P. O. Box 8747, Boston, MA
   date you receive a COBRA notice or would lose         02114-8747.
   group coverage due to one of the qualifying events
   described above. If you do not elect COBRA
                                                         Conversion to Non-Group
   coverage within the 60-day limit, your group
   health benefits coverage will end and you will lose   Health Coverage
   all rights to COBRA coverage.                         Under certain circumstances, a person whose
•	 You must make the first payment for COBRA             UniCare State Indemnity Plan coverage is ending
   coverage within 45 days after you elect COBRA.        has the option to convert to non-group health
   If you do not make your first payment for the         coverage provided by UniCare.
   entire COBRA cost due within that 45-day period,      A certificate for this non-group health coverage
   you will lose all COBRA coverage rights.              issued by UniCare can be obtained if:
                                                                                                                     General Provisions
                                                                                                                     Plan Definitions



•	 You must pay the subsequent monthly cost for          1. Employment for coverage purposes ends, except
   COBRA coverage in full by the end of the 30-day          due to retirement, or
   grace period after the due date on the bill. If you
   do not make payment in full by the end of the         2. Status changes occur for someone who is not
   30-day grace period after the due date on the bill,      eligible for continued coverage under the
   your COBRA coverage will end.                            UniCare State Indemnity Plan



                                                                                                                65
                     General Provisions


                     You cannot obtain a certificate of coverage if you       The following rules apply to the issuance of the
                     are otherwise eligible under the UniCare State           certificate of coverage:
                     Indemnity Plan, or if your coverage terminated
                                                                              1. Written application and the first premium must
                     for failure to make a required contribution when
                                                                                 be submitted within 31 days after the coverage
                     due. In addition, no certificate of coverage will
                                                                                 under the UniCare State Indemnity Plan ends.
                     be issued in a state or country where UniCare is
                     not licensed to issue it.                                2. The rules of UniCare for coverage available for
                                                                                 conversion purposes at the time application for
                     The certificate of coverage will cover you and your
                                                                                 a certificate of coverage is received govern the
                     dependent(s) who cease to be covered under the
                                                                                 certificate. Such rules include: the form of the
                     UniCare State Indemnity Plan because your health
                                                                                 certificate; its benefits; the individuals covered;
                     coverage ends, and any child of yours born within
                                                                                 the premium payable, and all other terms and
                     31 days after such coverage ends.
                                                                                 conditions of such certificate.
                     A certificate of coverage is also available to the
                                                                              3. If delivery of the certificate is to be made outside
                     following persons whose coverage under the
                                                                                 of Massachusetts, it may be on such form as is
                     UniCare State Indemnity Plan ceases:
                                                                                 offered in the state where such certificate is to
                     1. Your spouse and/or your dependent(s), if their           be delivered.
                        coverage ceases because of your death
                                                                              4. The certificate of coverage will become effective
                     2. Your child, covering only that child, if that child      on the day after coverage under the UniCare
                        ceases to be covered under the UniCare State             State Indemnity Plan ends.
                        Indemnity Plan solely because the child no
                                                                              5. No evidence of insurability will be required.
                        longer qualifies as your dependent
                                                                              UniCare will furnish details of converted coverage
                     3. Your spouse and/or dependent(s), if their
                                                                              upon request.
                        coverage ceases because of a change in
                        marital status
  Plan Definitions
General Provisions




                     66
PRESCRIPTION DRUG PLAN
           Description of Benefits




                       Administered by




                                    67
Prescription Drug Plan


CVS Caremark† is the pharmacy benefit manager                     Maintenance Drug
for your prescription drug benefit plan. The CVS                  A maintenance drug is a medication taken on a
Caremark pharmacy network includes major                          regular basis for chronic conditions such as asthma,
chain pharmacies nationwide, many independent                     diabetes, high-blood pressure or high-cholesterol.
pharmacies, a mail service pharmacy and
a specialty drug pharmacy.                                        Non-Preferred Brand-Name Drug
                                                                  A non-preferred brand-name drug, or non-formulary
The following benefit changes are effective July 1, 2011:         drug, is a medication that usually has an alternative
•	 Nexium and Aciphex will no longer be covered.                  therapeutically-equivalent drug available on
   Alternative over-the-counter, generic and brand-name           the formulary.
   drugs are covered.                                             Preferred Brand-Name Drug
•	 Preventive Drugs, as specified below, will be covered          A preferred brand-name drug, also known as
   at $0 copayment.                                               a formulary drug, is a medication that has been
                                                                  reviewed and approved by a group of physicians
If you have any questions about your prescription                 and pharmacists, and has been selected by CVS
drug benefits, contact CVS Caremark Customer Care                 Caremark for formulary inclusion based on its
toll free at (877) 876-7214, TDD: (800) 238-0756.                 proven clinical and cost-effectiveness.

About Your Plan                                                   Preventive Drugs
                                                                  Preventive drugs consist primarily of drugs
Prescription medications are covered by the plan                  recommended for coverage by the U.S. Preventive
only if they have been approved by the U.S. Food                  Services Task Force, and as specified by the federal
and Drug Administration (FDA). In addition, with                  Patient Protection and Affordable Care Act.
the exception of the over-the-counter versions of
omeprazole (omeprazole OTC), Prevacid (Prevacid                   Specialty Drugs
OTC), Prilosec (Prilosec OTC), Zegerid (Zegerid                   Specialty drugs are usually injectable and
OTC) and Preventive Drugs, medications are                        non-injectable biotech or biological drugs with
covered only if a prescription is required for their              one or more of several key characteristics, including:
dispensing. Diabetic supplies and insulin are also                •	 Potential for frequent dosing adjustments and
covered by the plan.                                                 intensive clinical monitoring to decrease the
The plan categorizes medications into seven                          potential for drug toxicity and to increase the
major categories:                                                    probability for beneficial treatment outcomes

Generic Drugs                                                     •	 Need for intensive patient training and compliance
Generic versions of brand medications contain the                    assistance to facilitate therapeutic goals
same active ingredients as their brand counterparts,              •	 Limited or exclusive product availability
thus offering the same clinical value. The FDA                       and distribution
requires generic drugs to be just as strong, pure and
stable as brand-name drugs. They must also be of                  •	 Specialized product handling and/or
the same quality and manufactured to the same                        administration requirements
rigorous standards. These requirements help to
assure that generic drugs are as safe and effective
as brand-name drugs.




†	CVS	Caremark	provides	services	through	its	operating	company	Caremark	PhC,	L.L.C.	and	affiliates.



68
Prescription Drug Plan


Over-the-Counter (OTC) Drugs                              Copayments
Over-the-counter drugs are medications that do not
require a prescription. Your plan does not provide        One of the ways your plan maintains coverage of
benefits for OTC drugs, with the exception of             quality, cost-effective medications is a multi-tier
omeprazole OTC, Prevacid OTC, Prilosec OTC,               copayment pharmacy benefit: Tier 1 (most generic
Zegerid OTC and Preventive Drugs (all of which are        drugs), Tier 2 (mostly preferred brand-name drugs),
covered only if dispensed with a written prescription).   Tier 3 (non-preferred brand-name drugs), or
                                                          Preventive Drugs. The following chart shows your
                                                          copayment based on the type of prescription you fill
                                                          and where you get it filled.



                                                          Participating Retail        Mail Service or
                                                          Pharmacy up to              CVS/pharmacy up
Copayment for                                             30-day supply               to 90-day supply

Tier 1
Generic Drugs and
    O
•	 		 meprazole	OTC,	Prevacid	OTC,	Prilosec	OTC	
                                                                     $10                       $20
    and Zegerid OTC (28-day supply – retail;
    84-day supply – mail) †

Tier 2
Preferred Brand-Name Drugs and
    G
•	 		 eneric	versions	of	Prevacid	(lansoprazole),	
                                                                     $25                       $50
    Protonix (pantoprazole) and Zegerid (omeprazole/
    sodium bicarbonate)

Tier 3
                                                                     $50                       $110
Non-Preferred Brand-Name Drugs

Preventive Drugs
    R
•	 		 efer	to	the	“Preventive	Drugs”	section	below	for	               $0                        $0
    detailed information

                                                          Specialty Drugs – Two 30-day prescriptions
                                                          allowed at any participating pharmacy;
                                                          thereafter must be filled only through
Copayment for                                             CVS Caremark Specialty Pharmacy

Specialty Drugs: Tier 1                                               $10 up to a 30-day supply
Specialty Drugs: Tier 2                                               $25 up to a 30-day supply
Specialty Drugs: Tier 3                                               $50 up to a 30-day supply




† Due to manufacturer packaging



                                                                                                            69
Prescription Drug Plan


How to Use the Plan                                      You can locate the nearest participating retail
                                                         pharmacy anytime online after registering at
After you first enroll in the plan, CVS Caremark         www.caremark.com or by calling toll free at
will send you a benefit booklet and CVS Caremark         (877) 876-7214.
Prescription Card(s) for you and your dependent(s).
Your Prescription Card(s) will be mailed to you          If you do not have your Prescription Card, you can
and your dependents (if any) in separate mailings        provide your pharmacist with the cardholder’s Social
from the benefit booklet. (Please note: You may          Security or GIC ID number, Bin number (610029),
receive Prescription Cards for your dependent(s)         group code (GICRX) and the RxPCN code (CRK).
before you receive the benefit booklet.)                 The pharmacist can also verify eligibility by
                                                         contacting the CVS Caremark Pharmacy Help Desk
Show your new Prescription Card to your pharmacy         toll free at (800) 421-2342, TDD: (800) 238-0756.
so they can correctly process your prescription
drug benefits.                                           Maintenance Medications – Up to 30 Days
                                                         After you fill two 30-day supplies of a maintenance
Register on www.caremark.com. As a registered            medication at a retail pharmacy, you will be
user, you can check drug costs, order mail service       contacted by CVS Caremark to explain how you may
refills, and review your prescription drug history.      convert your prescription to a 90-day supply to be
You can access this site 24 hours a day.                 filled either through mail service or at a CVS/
Filling Your Prescriptions                               pharmacy. You will receive coverage for additional
You may fill your prescriptions for non-specialty        fills of the medication only if you convert your
drugs at any participating retail pharmacy, or           prescription to 90-days, or if you inform CVS
through the CVS Mail Service Pharmacy.                   Caremark that you prefer to continue to receive
Prescriptions for specialty drugs must be filled         30-day supplies at a retail pharmacy.
as described in the “CVS Caremark Specialty              CVS Caremark will assist you in transitioning your
Pharmacy” subsection.                                    maintenance prescription to either mail service or
To obtain benefits at a retail pharmacy, you must fill   a CVS/pharmacy location.
your prescription at a participating pharmacy using      Maintenance Medications – Up to 90 Days
your CVS Caremark Prescription Card, with the            Filling 90-day Prescriptions through CVS Caremark
exception of the limited circumstances detailed in       Mail Service Pharmacy or CVS/pharmacy
the “Claim Forms” subsection.                            You have the choice and convenience of filling
Short-Term Medications – Up to 30 Days                   maintenance prescriptions for up to a 90-day supply
Filling Your Prescriptions at a Participating            at the mail service copayment, either through the
Retail Pharmacy                                          CVS Caremark Mail Service Pharmacy or at a
The retail pharmacy is your most convenient option       CVS/pharmacy.
when you are filling a prescription for a short-term     Mail service is a convenient option for prescription
prescription that you need immediately (example:         drugs that you take on a regular basis for conditions
antibiotics for strep throat or painkillers for an       such as asthma, diabetes, high-blood pressure, and
injury). Simply present your CVS Caremark                high-cholesterol. Your prescriptions are filled and
Prescription Card to your pharmacist, along with         conveniently sent to you in a plain, weather-resistant
your written prescription, and pay the required          pouch for privacy and protection. They are delivered
copayment. Prescriptions filled at a non-participating   directly to your home or to another location that
retail pharmacy are not covered.                         you prefer.




70
Prescription Drug Plan


CVS/pharmacy is another option for getting your          CVS Caremark Specialty Pharmacy
90-day maintenance medications for the same              CVS Caremark Specialty Pharmacy is a full-service
copayment amount as mail service. Prescriptions          specialty pharmacy that provides personalized
can be filled at one of over 7,000 CVS/pharmacy          care to each patient. You are allowed two fills of a
locations across the country.                            specialty drug at any participating retail pharmacy.
                                                         After these two fills, a specialty drug must be filled
Convenient for You
                                                         only at the CVS Caremark Specialty Pharmacy.
You get up to a 90-day supply of your maintenance
medications – which means fewer refills and fewer        Specialty medications may be filled only at a
visits to your pharmacy, as well as lower copayments.    maximum of 30-days supply. They are subject to
Once you begin using mail service, or the option         a clinical review by CVS Caremark’s Specialty
of your local CVS/pharmacy, you can order refills        Guideline Management program to ensure the
online or by phone.                                      medications are being prescribed appropriately.
Using Mail Service                                       CVS Caremark Specialty Pharmacy offers a complete
To begin using mail service for your prescriptions,      range of services and specialty drugs. Your specialty
just follow these three simple steps:                    drugs are quickly delivered to any approved location,
                                                         at no additional charge. You have toll-free access
1. Ask your physician to write a prescription for
                                                         to expert clinical staff who are available to answer
   up to a 90-day supply of your maintenance
                                                         all of your specialty drug questions. CVS Caremark
   medication plus refills for up to one year, if
                                                         Specialty Pharmacy will provide you with ongoing
   appropriate. (Remember also to ask for a second
                                                         refill reminders before you run out of your
   prescription for an initial 30-day supply and take
                                                         medications.
   it to your local participating retail pharmacy.)
                                                         To begin receiving your specialty drugs through
2. Complete a mail order form (contained in your
                                                         CVS Caremark Specialty Pharmacy, call toll free
   Welcome Kit or found online after registering at
                                                         at (800) 237-2767.
   www.caremark.com). Or call CVS Customer Care
   toll free at (877) 876-7214 to request the form.      CVS Caremark Specialty Pharmacy Services
3. Put your prescription, payment and completed          •	 Patient Counseling – Convenient access to
   order form into the return envelope (provided            pharmacists and nurses who are specialty
   with the order form) and mail it to CVS Caremark.        medication experts

Please allow 7-10 business days for delivery from        •	 Patient Education – Educational materials
the time your order is mailed. A pharmacist is           •	 Convenient Delivery – Coordinated delivery to
available 24 hours a day to answer your questions           your home, your doctor’s office, a CVS/pharmacy
about your medication.                                      or other approved location
If the CVS Caremark Mail Service Pharmacy is             •	 Refill Reminders – Ongoing refill reminders from
unable to fill a prescription because of a shortage of      CVS Caremark Specialty Pharmacy
the medication, CVS Caremark will notify you of the
delay in filling the prescription. You may then fill     •	 Language Assistance – Language interpreting
the prescription at a retail pharmacy, but the retail       services are provided for non-English speaking
pharmacy copayment will apply.                              patients
                                                         CVS Caremark Specialty Pharmacy serves a wide
                                                         range of patient populations, including those with
                                                         hemophilia, hepatitis, cancer, multiple sclerosis and
                                                         rheumatoid arthritis.



                                                                                                              71
 Prescription Drug Plan


 Claim Forms                                                           Other Plan Provisions
 Retail purchases out of the country, or purchases at
                                                                       Preventive Drugs
 a participating retail pharmacy without the use of
                                                                       Coverage will be provided for the following drugs*:
 your CVS Caremark Prescription Card, are covered
 as follows:                                                           •	 Aspirin: Generic OTC versions when prescribed
                                                                          for adults age 45 or older for the prevention of
   Type of Claim            Reimbursement                                 heart attack or stroke
   Claims for               Claims will be reimbursed at               •	 Birth control drugs: Generic versions of oral and
   prescriptions for        the full cost submitted less                  non-oral drugs
   plan members             the applicable copayment.
   who reside in a                                                     •	 Folic acid supplements: Generic OTC versions
   nursing home or                                                        when prescribed for women under the age of 56
   live or travel                                                         planning or capable of pregnancy
   outside the U.S.
                                                                       •	 Immunization vaccines: Generic or brand
   or Puerto Rico.†
                                                                          versions prescribed for children or adults
   Claims for               Claims incurred within
   purchases at             30 days of the member’s                    •	 Iron supplements: Generic, brand and OTC
   a participating          eligibility effective date will               supplements when prescribed for children one
   (in-network)             be covered at full cost, less                 year of age or under who are at increased risk
   pharmacy without         the applicable copayment.                     for iron deficiency anemia
   a	CVS	Caremark	
                            -or-                                       •	 Oral fluoride supplements: Generic and brand
   Prescription
   Card.                    Claims incurred more than                     supplements prescribed for children six years of
                            30 days after the member’s                    age or under for the prevention of dental caries
                            eligibility effective date will            •	 Tobacco cessation: Generic, brand and OTC
                            be reimbursed at a                            products prescribed for adults for the purpose
                            discounted cost, less the
                                                                          of smoking cessation
                            applicable copayment.
                                                                       Call CVS Caremark Customer Care at (877) 876-7214
                                                                       for additional coverage information on specific
                                                                       Preventive Drugs.
† Claims for medications filled outside the United States
  and Puerto Rico are covered only if the medications have             Brand-Name Drugs with Exact
  U.S. equivalents.
                                                                       Generic Equivalents
                                                                       The plan encourages the use of generic drugs. There
                                                                       are some brand-name drugs, such as Ambien and
                                                                       Fosamax, for which exact generic equivalents are
                                                                       available. If you fill a prescription for a brand-name
                                                                       medication for which there is an exact generic
                                                                       equivalent, the standard brand copayment will not
                                                                       apply. Instead, you will be responsible for the full
                                                                       difference in price between the brand-name drug
                                                                       and the generic drug, plus the generic copayment.
                                                                       This provision is not applicable to Preventive Drugs.

 *	This	list	is	subject	to	change	during	the	year.	Call	CVS	Caremark	toll	free	at	(877)	876-7214	to	check	if	your	drugs	are	included	in	
 the program.



 72
Prescription Drug Plan


Prescription Drugs with OTC Equivalents                                Current examples of drugs requiring
or Alternatives                                                        Prior Authorization*
Some prescription drugs have OTC equivalent                            Actemra              Immune                Ribavirin
products available. These OTC products have                            Actiq                 Globulin             Sandostatin
strengths, active chemical ingredients, routes of                      Amevive               Products             Sensipar
administration and dosage forms identical to the                       Ampyra               Kineret               Simponi
prescription drug products. Your plan does not                         Anabolic             Lamisil               Somavert
provide benefits for prescription drugs with OTC                        Steroids            Letairis              Sporanox
equivalents. This provision is not applicable to                        such as             Lupron                Stelara
Preventive Drugs.                                                       Anadrol and         Myobloc               Supartz
                                                                        Oxandrin            Neulasta              Synvisc
Some prescription drugs also have OTC product                          Aralast              Neupogen              Tazorac
alternatives available. These OTC products, though                     Aranesp              Nutritional           Testosterone
not identical, are very similar to the prescription                    Avonex                Supplements           Products
drugs. For example, OTC alternatives to Clarinex,                      Betaseron            Nuvigil                such as
a prescription drug, are the OTC products Allegra,                     Botox                Orencia                Androderm,
Claritin and Zyrtec. Your plan does not provide                        Byetta               Orthovisc              Androgel,
benefits for prescription drugs when OTC alternatives                  Cerezyme             Pegasys                and Testim
                                                                       Cimzia               Peg-Intron            Thyrogen
are available. This provision is not applicable to
                                                                       Copaxone             Penlac                Tobi
Preventive Drugs.
                                                                       Enbrel               Pradaxa               Tracleer
Prior Authorization                                                    Epogen               Privigen              Tysabri
Some drugs in your plan require prior authorization.                   Euflexxa             Procrit               Vfend
If a drug that you take requires prior authorization,                  Exjade               Prolastin             Victoza
                                                                       Fabrazyme            Prolia                Vivitrol
your physician will need to contact CVS Caremark
                                                                       Fentora              Provigil              Weight Loss
to see if the prescription meets the plan’s conditions
                                                                       Forteo               Pulmozyme              Drugs such
for coverage. If you are prescribed a drug that                        Gilenya              Raptiva                as Xenical
requires prior authorization, your physician should                    Growth               Rebif                 Xenazine
call (800) 626-3046.                                                    Promoting           Reclast               Xiaflex
                                                                        Agents              Regranex              Xolair
                                                                       Humira               Remicade              Xyrem
                                                                       Hyalgan              Revatio               Zemaira

                                                                       For members over the age of 35: Retin-A,
                                                                       Retin-A Micro, Avita, Tretin-X, Atralin gel, topical
                                                                       tretinoin,	Veltin,	Ziana

                                                                      Quantity Dispensing Limits
                                                                      To promote member safety and appropriate and
                                                                      cost-effective use of medications, your prescription
                                                                      plan includes a drug quantity management
                                                                      program. This means that for certain prescription
                                                                      drugs, there are limits on the quantity of the drug
                                                                      that you may receive at one time.


*	This	list	is	subject	to	change	during	the	year.	Call	CVS	Caremark	toll	free	at	(877)	876-7214	to	check	if	your	drugs	are	included	in	
the program.



                                                                                                                                    73
Prescription Drug Plan


Quantity per dispensing limits are based on                           changed, or you will have to pay the full cost of the
the following:                                                        prescription. If you are using mail service, CVS
                                                                      Caremark will notify you of a delay in filling your
•	 The manufacturer’s recommended dosage
                                                                      prescription and will contact your physician about
   and duration of therapy
                                                                      switching to a first-line prescription drug. If your
•	 Common usage for episodic or                                       physician does not respond within two business
   intermittent treatment                                             days, CVS Caremark will not fill your prescription
                                                                      and will return it to you.
•	 FDA-approved recommendations and/or
   clinical studies                                                    Current examples of prescription drugs
                                                                       requiring Step Therapy*
•	 As otherwise determined by your plan
                                                                       ADD/ADHD           Strattera, Intuniv
Examples of drugs with quantity limits currently                       Allergies & Asthma Accolate,	Beconase	AQ,	
include Flonase, Imitrex, Levitra, and Viagra.*                                           Omnaris, Nasacort AQ,
                                                                                          Nasonex, Rhinocort Aqua,
Step Therapy
                                                                                          Singulair,	Veramyst,	Xopenex	
In some cases, your plan requires the use of less
                                                                                          Nebulizer	Solution,	Zyflo/CR	
expensive first-line prescription drugs before the plan
                                                                       Antidepressants    Cymbalta, Lexapro, Luvox CR,
will pay for more expensive second-line prescription
                                                                                          Pexeva, Pristiq, Sarafem,
drugs. First-line prescription drugs are safe and                                         Savella
effective medications used for the treatment of
                                                                       Anti-infectives    Solodyn
medical conditions or diseases. Your prior claims
                                                                       Antipsychotics     Symbyax
history, if you are a continuing member of the plan,
will show whether first-line prescription drugs have                   Benign	Prostatic	 Avodart, Jalyn
been purchased within the previous 180 days,                           Hypertrophy	(BPH)
allowing the second-line medication to be approved                     Diabetes           Actos, Actoplus Met,
without delay.                                                                            Avandia, Avandamet,
                                                                                          Avandaryl, Duetact
If you have not had a medication filled within the                     Gout               Uloric
previous 180 days while a member of this plan,                         High-Blood	        Atacand/HCT, Avapro, Avalide,
a first-line prescription drug must be used and                        Pressure           Azor,	Benicar/HCT,	Bystolic,	
the Step Therapy requirements will apply to                                               Coreg CR, Diovan/HCT,
your prescription.                                                                        Exforge/HCT, Innopran XL,
                                                                                          Micardis/HCT, Tekalmo,
In certain situations, a member may be granted an
                                                                                          Tekturna/HCT, Teveten/HCT,
authorization for a second-line prescription drug                                         Tribenzor,	Twynsta,	Valturna	
without the prior use of a first-line prescription drug
                                                                       High-Cholesterol Advicor, Altoprev, Caduet,
if specific medical criteria have been met.                                               Crestor, Lescol/XL, Lipitor,
Unless you meet certain medical criteria or have a                                        Livalo,	Simcor,	Vytorin,	Zetia
prior history of use of the first-line prescription                    Incontinence       Detrol, Detrol LA, Enablex,
drug, your pharmacist will receive a message that                                         Gelnique, Oxytrol,
the prescription will not be covered. The message                                         Sanctura XR, Toviaz,
will list alternative, first-line drugs that could be                                     VESIcare
used. You or your pharmacist will then need to                         Insomnia           Edluar, Lunesta, Rozerem,
contact your physician to have your prescription                                          Silenor, Zolpimist
                                                                       Neuropathy         Lyrica
*	This	list	is	subject	to	change	during	the	year.	Call	CVS	Caremark	toll	free	at	(877)	876-7214	to	check	if	your	drugs	are	included	in	
the program.



74
Prescription Drug Plan


Current examples of prescription drugs                        Exclusions
requiring Step Therapy* (continued)
                                                              Benefits exclude:†
Osteoporosis             Actonel, Actonel Plus
                         Calcium,	Atelvia,	Boniva,	           •	 Nexium and Aciphex
                         Fosamax Plus D, Fosamax
                         Solution, Skelid                     •	 Dental preparations, with the exception of oral
                                                                 fluoride Preventive Drugs for children six years
Pain/Arthritis           Arthrotec, Cambia, Celebrex,
                                                                 of age or under
                         Flector, Naprelan CR,
                         Pennsaid	,Vimovo,	                   •	 Over-the-counter drugs, vitamins or minerals
                         Voltaren	gel,	Zipsor	                   (with the exception of diabetic supplies, or OTC
Stomach Ulcers           Dexilant, lansoprazole,                 versions of omeprazole, Prevacid, Prilosec,
                         omeprazole/sodium                       Zegerid and Preventive Drugs)
                         bicarbonate, pantoprazole,
                         Prilosec packets,                    •	 Non-sedating antihistamines
                         Protonix, Protonix packets,
                                                              •	 Homeopathic drugs
                         Zegerid packets
Topical Dermatitis       Elidel, Protopic                     •	 Prescription products for cosmetic purposes
Topical Steroids         Brand	Topical	Steroid	                  such as photo-aged skin products and skin
                         products such as Clobex,                depigmentation products
                         Derma-Smoothe, Locoid,
                                                              •	 Medications in unit dose packaging
                         Luxiq,	Olux,	Vanos
*	This	list	is	subject	to	change	during	the	year.	Call	CVS	   •	 Impotence medications for members under the
Caremark toll free at (877) 876-7214 to check if your drugs      age of 18
are included in the program.
                                                              •	 Allergens
Drug Utilization Review Program
                                                              •	 Hair growth agents
Each prescription drug purchased through this
plan is subject to utilization review. This process           •	 Special medical formulas or food products, except
evaluates the prescribed drug to determine if any                as required by state law
of the following conditions exist:                            † This list is subject to change during the year.
•	 Adverse drug-to-drug interaction with another
   drug purchased through the plan;                           Definitions
•	 Duplicate prescriptions;                                   Brand-Name Drug – The brand name is the trade
                                                              name under which the product is advertised and
•	 Inappropriate dosage and quantity; or                      sold, and is protected by patents so that it can only
•	 Too early refill of a prescription.                        be produced by one manufacturer for 17 years. Once
                                                              a patent expires, other companies may manufacture
If any of the above conditions exist, medical necessity       a generic equivalent, providing they follow stringent
must be determined before the prescription drug               FDA regulations for safety.
can be filled.
                                                              Copayment – A copayment is the amount that
                                                              members pay for covered prescriptions. If the plan’s
                                                              contracted cost for a medication is less than the
                                                              applicable copayment, the member pays only the
                                                              lesser amount.




                                                                                                                    75
Prescription Drug Plan


Diabetic Supplies – Diabetic supplies include             Participating Pharmacy – A participating pharmacy
needles, syringes, test strips, lancets and blood         is a pharmacy in the CVS Caremark nationwide
glucose monitors.                                         network. All major pharmacy chains and most
                                                          independently-owned pharmacies participate.
FDA – The U.S. Food and Drug Administration.
                                                          Preferred Brand-Name Drug – A preferred brand-
Formulary – A formulary is a list of recommended
                                                          name drug, also known as a formulary drug, is a
prescription medications that is created, reviewed
                                                          medication that has been reviewed and approved
and continually updated by a team of physicians and
                                                          by a group of physicians and pharmacists, and
pharmacists. The CVS Caremark formulary contains
                                                          has been selected by CVS Caremark for formulary
a wide range of generic and preferred brand-name
                                                          inclusion based on its proven clinical and cost-
products that have been approved by the FDA. The
                                                          effectiveness.
formulary applies to medications that are dispensed
in either the retail pharmacy or mail service settings.   Prescription Drug – A prescription drug is any
The formulary is developed and maintained by CVS          medical substance, the label of which under the
Caremark. Formulary designations may change as            Federal Food, Drug, and Cosmetic Act, must bear
new clinical information becomes available.               the legend: “Caution: Federal Law prohibits
                                                          dispensing without a prescription.” The term
Generic Drugs – Generic versions of brand
                                                          prescription drug also includes insulin and
medications contain the same active ingredients as
                                                          diabetic supplies.
their brand counterparts, thus offering the same
clinical value. The FDA requires generic drugs to         Preventive Drugs – Preventive drugs consist
be just as strong, pure and stable as brand-name          primarily of drugs recommended for coverage
drugs. They must also be of the same quality and          by the U.S. Preventive Services Task Force, and
manufactured to the same rigorous standards.              as specified by the federal Patient Protection
These requirements assure that generic drugs are          and Affordable Care Act.
as safe and effective as brand-name drugs.
                                                          Prior Authorization – Prior authorization means
Maintenance Drug – A maintenance drug is a                determination of medical necessity. It is required
medication taken on a regular basis for conditions        before prescriptions for certain drugs will be paid
such as asthma, diabetes, high-blood pressure or          for by the plan.
high-cholesterol.
                                                          Special Medical Formulas or Food Products –
Non-Preferred Brand-Name Drug – A non-preferred           Special medical formulas or food products means
brand-name drug, or non-formulary drug, is                nonprescription enteral formulas for home use for
a medication that has been reviewed by CVS                which a physician has issued a written order and
Caremark, which determined that an alternative            which are medically necessary for the treatment of
drug that is clinically equivalent and more cost-         malabsorption caused by Crohn’s disease, ulcerative
effective may be available.                               colitis, gastroesophageal reflux, gastrointestinal
                                                          motility, chronic intestinal pseudo-obstruction, and
Over-the-Counter (OTC) Drugs – Over-the-counter
                                                          inherited diseases of amino acids and organic acids.
drugs are medications that do not require a
                                                          These products may require prior authorization to
prescription. Your plan does not provide benefits
                                                          determine medical necessity.
for OTC drugs, with the exception of omeprazole
OTC, Prevacid OTC, Prilosec OTC, Zegerid OTC              For inherited diseases of amino acids and organic
and OTC versions of Preventive Drugs (all of              acids, food products modified to be low protein are
which are covered only if dispensed with a                covered up to $5,000 per calendar year per member.
written prescription).




76
Prescription Drug Plan


To access the benefit for special medical formulas       Internal Inquiry
or food products, call the Group Insurance               Call Customer Care to discuss concerns you may have
Commission at (617) 727-2310, extension 1.               regarding your prescription drug coverage. Every
                                                         effort will be made to resolve your concerns. If your
Specialty Drugs – Specialty drugs are usually
                                                         concerns cannot be resolved or if you tell a Customer
injectable and non-injectable biotech or biological
                                                         Care representative you are not satisfied with the
drugs with one or more of several key
                                                         response you have received, Customer Care will
characteristics, including:
                                                         notify you of any options you may have, including
•	 Requirement for frequent dosing adjustments           the right to have your inquiry processed as an appeal.
   and intensive clinical monitoring to decrease         Customer Care will also provide you with the steps
   the potential for drug toxicity and to increase the   you and your doctor must follow to submit an appeal.
   probability for beneficial treatment outcomes
                                                         Internal Member Appeals
•	 Need for intensive patient training and compliance    Requests for coverage that were denied as specifically
   assistance to facilitate therapeutic goals            excluded in this member handbook or for coverage
                                                         that was denied based on medical necessity
•	 Limited or exclusive product availability
                                                         determinations are reviewed as appeals through
   and distribution
                                                         CVS Caremark’s Internal Appeals Process. You may
•	 Specialized product handling and/or                   file an appeal request yourself or you may designate
   administration requirements                           someone to act on your behalf in writing. You have
                                                         180 days from the date you were notified of the
Step Therapy – Step Therapy is a program which
                                                         denial of benefit coverage or prescription drug claim
requires the use of less expensive first-line
                                                         payment to file your appeal.
prescription drugs before the plan will pay for more
expensive second-line prescription drugs.                (i) You must submit a written appeal to the address
                                                             listed above. Your letter should include:
Other Plan Information                                      •	 Your complete name and address;
Member Appeals                                              •	 Your CVS Caremark ID number;
CVS Caremark has processes to address:
                                                            •	 Your Date of Birth;
•	 Inquiries concerning your drug coverage
                                                            •	 A detailed description of your concern,
•	 Appeals:                                                    including the drug name(s) being requested; and
   − Internal Member Appeals
                                                            •	 Copies of any supporting documentation,
   − Expedited Appeals
                                                               records or other information relating to the
   − External Review Appeals
                                                               request for appeal
All appeals should be sent to CVS Caremark
                                                         (ii) The CVS Caremark Appeals Department will
at the following address:
                                                              review appeals concerning specific prescription
CVS Caremark                                                  drug benefit provisions, plan rules, and exclusions
Appeals Department                                            and make determinations. If you are not satisfied
MC109                                                         with an Appeals Department denial related to
P.O. Box 52084                                                a plan rule or exclusion (i.e., non-medical
Phoenix, AZ 85072-2084                                        necessity appeal), you may have the right to
Fax Number: (866) 689-3092                                    request an independent External Review of the
                                                              decision (refer to the “External Review Appeals”
All calls should be directed to Customer Care at
                                                              section for details on this process).
(877) 876-7214.


                                                                                                              77
Prescription Drug Plan


     For denials related to a medical necessity                the medical condition for which the prescription
     determination, you have the right to an additional        drug has been prescribed. CVS Caremark will notify
     review by CVS Caremark. CVS Caremark will                 you of its decision by telephone no later than 72 hours
     request this review from an independent                   after CVS Caremark’s receipt of the request.
     practitioner in the same or in a similar specialty
                                                               External Review Appeals
     that typically manages the medical condition for
                                                               In most cases, if you do not agree with the Appeals
     which the prescription drug has been prescribed.
                                                               decision, you or your authorized representative have
     If the second review is an adverse determination,
                                                               the right to request an independent, external review
     you have the right to request an External Review
                                                               of the decision. Should you choose to do so, send
     of this decision (refer to the “External Review
                                                               your request within four months of your receipt of
     Appeals” section for details on this process).
                                                               the written notice of the denial of your appeal to:
(iii) For an appeal on a prescription drug that has not
                                                               CVS Caremark
      been dispensed, an Appeals Analyst will notify
                                                               External Review Appeals Department
      you in writing of the decision within no more than
                                                               MC109
      fifteen (15) calendar days of the receipt of an
                                                               P.O. Box 52084
      appeal. For an appeal on a prescription drug already
                                                               Phoenix, AZ 85072-2084
      dispensed, an Appeals Analyst will notify you
                                                               Fax Number: (866) 689-3092
      in writing of the decision within no more than
      thirty (30) calendar days of the receipt of an appeal.   In some cases, members may have the right to an
                                                               expedited external review. An expedited external
     A copy of the decision letter will be sent to you
                                                               review may be appropriate in urgent situations.
     and your physician. A determination of denial
                                                               Generally, an urgent situation is one in which your
     will set forth:
                                                               health may be in serious jeopardy, or, in the opinion
     •	 CVS Caremark’s understanding of the request;           of your physician, you may experience pain that
     •	 The reason(s) for the denial;                          cannot be adequately controlled while you wait for
     •	 Reference to the contract provisions on which          a decision on your appeal.
        the denial is based; and
                                                               If you request an external review, an independent
     •	 A clinical rationale for the denial, if the appeal
                                                               organization will review the decision and provide
        involves a medical necessity determination.
                                                               you with a written determination. If this organization
CVS Caremark maintains records of each inquiry                 decides to overturn the Appeals decision, the service
made by a member or by that member’s designated                or supply will be covered under the plan.
representative.
                                                                If You Have Questions
Expedited Appeals                                               If you have questions or need help submitting
CVS Caremark recognizes that there are circumstances            an appeal, please call Customer Care for
that require a quicker turnaround than allotted for             assistance at (877) 876-7214.
the standard Appeals Process. CVS Caremark will
expedite an appeal when a delay in treatment would             Health and Prescription Information
seriously jeopardize your life and health or                   Health and prescription information about members
jeopardize your ability to regain maximum function.            is used by CVS Caremark to administer benefits. As
If your request does not meet the guidelines for an            part of the administration, CVS Caremark may report
expedited appeal, CVS Caremark will explain your               health and prescription information to the
right to use the standard appeals process.                     administrator or sponsor of the benefit plan. CVS
                                                               Caremark also uses that information and prescription
If your request meets the guidelines for an expedited
                                                               data gathered from claims nationwide for reporting
appeal, it will be reviewed by a practitioner in the
                                                               and analysis without identifying individual members.
same or in a similar specialty that typically manages

78
MENTAL HEALTH, SUBSTANCE ABUSE AND
    ENROLLEE ASSISTANCE PROGRAMS
                   Description of Benefits




                               Administered by




                                            79
Mental Health, Substance Abuse and Enrollee Assistance Programs


  Part I – How to Use this Plan
As a member of this plan, you are automatically         How to Ensure Optimal Benefits
enrolled in the mental health and substance abuse
benefits program, as well as the Enrollee Assistance    In order to receive optimal benefits and reduce your
Program (EAP), administered by United Behavioral        out-of-pocket expenses, there are two important
Health. These programs offer you easy access to         steps you need to remember:
a broad range of services – from assistance with        Step 1: Call UBH/OptumHealth Behavioral
day-to-day concerns (e.g., legal and financial          Solutions for referral information and pre-certification
consultations, workplace-related stress, childcare      for non-routine services before you seek EAP,
and eldercare referrals) to more acute mental health    mental health or substance abuse services; and
and substance abuse needs, including but not
limited to assistance in a psychiatric emergency.       Step 2: Use a provider or facility from the UBH/
By offering effective, goal-focused care delivered      OptumHealth Behavioral Solutions network.
by a network of highly qualified providers, this        UBH/OptumHealth Behavioral Solutions offers
program is designed to improve the well-being and       you a comprehensive in-network of resources and
functioning of our members as quickly as possible.      experienced providers from which to obtain EAP,
United Behavioral Health (UBH) administers the          mental health and substance abuse services.
benefits under this program on behalf of the Group      All UBH/OptumHealth Behavioral Solutions
Insurance Commission (GIC). Since January 1,            in-network providers have been reviewed by UBH/
2009, UBH has been operating under the brand            OptumHealth Behavioral Solutions for their ability
name of OptumHealth Behavioral Solutions. Please        to provide quality care. If you receive care from a
note that this is only a brand name, and it does not    provider or facility that is not part of the UBH/
affect any of UBH’s operations and procedures as        OptumHealth Behavioral Solutions network, your
described in this Handbook. The corporate entity        benefit level will be lower than the in-network level.
is still registered as United Behavioral Health.        These reduced benefits are defined as out-of-network
                                                        benefits. If you do not call UBH/OptumHealth
Let Us Show You the Benefits                            Behavioral Solutions (1-888-610-9039; TDD:
                                                        1-800-842-9489) to pre-certify non-routine services and
The following section describes your mental health,     obtain referral information for your care, you may
substance abuse and EAP benefits under the UBH/         be charged a penalty and your benefits may be
OptumHealth Behavioral Solutions plan. Please           reduced. In some instances if you fail to pre-certify
review these carefully before you seek care to ensure   your care for non-routine services, no benefits will be
that you receive optimal behavioral health benefits.    paid. Please refer to Part III, “Benefits Explained,”
The chart on pages 90-91 provides a brief overview      on page 92, for a full description of your in-network
of your benefits; however, it is not a detailed         and out-of-network benefits, as well as special
description. The detailed description of your           pre-certification requirements for out-of-network
benefits is found in Part III on pages 92-98. Words     outpatient services. BENEFITS WILL BE DENIED
in italics throughout this description are defined in   IF YOUR CARE IS CONSIDERED NOT TO BE A
the “Definitions” section in Part II.                   COVERED SERVICE.




Words in italics are defined in Part II.



80
Mental Health, Substance Abuse and Enrollee Assistance Programs


Before You Use Your Benefits                                      The UBH/OptumHealth Behavioral Solutions
                                                                  clinician will also pre-certify any non-routine service
Referral/Pre-Certification for                                    requests. UBH/OptumHealth Behavioral Solutions
Non-Routine Services                                              maintains an extensive database of information on
Contacting UBH/OptumHealth Behavioral                             every provider in the network. (A directory of UBH/
Solutions is the first step to obtaining your EAP,                OptumHealth Behavioral Solutions providers can
mental health and substance abuse benefits.                       be found on the UBH/OptumHealth Behavioral
To receive EAP services, or before you begin mental               Solutions website, www.liveandworkwell.com
health and substance abuse care, call UBH/                        (access code 10910). After pre-certification, you can
OptumHealth Behavioral Solutions at                               then call the provider directly to schedule an
1-888-610-9039 (TDD: 1-800-842-9489).                             appointment. The UBH/OptumHealth Behavioral
A trained UBH/OptumHealth Behavioral Solutions                    Solutions clinician can also provide you with
clinician will answer your call 24 hours a day, seven             a referral for legal, financial, or dependent care
days a week, verify your coverage and refer you to a              assistance or community resources, depending
specialized EAP resource or an in-network provider.               on your specific needs.
All UBH/OptumHealth Behavioral Solutions clinicians
are experienced professionals with master’s degrees               Emergency Care
in psychology, social work or a related field. A UBH/             Emergency care is required when a person needs
OptumHealth Behavioral Solutions clinician will                   immediate clinical attention because he or she
immediately be available to assist you with routine               presents a real and significant risk to himself or
matters or in an emergency. If you have specific                  herself or others. In a life-threatening emergency,
questions about your benefits or claims, call a                   you and/or your covered dependents should seek
customer service representative from 9 a.m. to                    care immediately at the closest emergency facility.
8 p.m. Eastern time at 1-888-610-9039                             You, a family member or your provider must call
(TDD: 1-800-842-9489).†                                           UBH/OptumHealth Behavioral Solutions within
Based on your specific needs, the UBH/OptumHealth                 24 hours of an emergency admission to notify
Behavioral Solutions clinician will verify whether you            UBH/OptumHealth Behavioral Solutions of the
are eligible for coverage at the time of your call,               admission. Although a representative may call on
and provide you with the names of several mental                  your behalf, it is always the member’s responsibility
health, substance abuse or EAP providers who                      to make certain that UBH/OptumHealth Behavioral
match your request (e.g., provider location, gender,              Solutions has been notified of an emergency
or fluency in a second language). If you need                     admission. If you need assistance with scheduling
assistance with scheduling an appointment with                    an appointment with an in-network provider,
an in-network provider, a UBH/OptumHealth                         a UBH/OptumHealth Behavioral Solutions clinician
Behavioral Solutions clinician can make the                       can make the appointment for you. If UBH/
appointment for you.                                              OptumHealth Behavioral Solutions is not notified
                                                                  of an admission, then a member may not be eligible
                                                                  for optimal benefits, or claims may be denied.




†	As	part	of	the	UBH/OptumHealth	Behavioral	Solutions	quality	control	program,	supervisors	monitor	random	calls	to	the	
UBH/OptumHealth	Behavioral	Solutions	customer	services	department.	
Words in italics are defined in Part II.



                                                                                                                          81
Mental Health, Substance Abuse and Enrollee Assistance Programs


Urgent Care                                              Confidentiality
There may be times when a condition shows                When you use your EAP, mental health and
potential for becoming an emergency if not treated       substance abuse benefits under this plan, you are
immediately. In such urgent situations, our providers    consenting to the release of necessary clinical
will have an appointment to see you within 24 hours      records to UBH/OptumHealth Behavioral Solutions
of your initial call to UBH/OptumHealth Behavioral       for case management and benefit administration
Solutions. If you need assistance with scheduling        purposes. Information from your clinical records
an appointment with an in-network provider,              will be provided to UBH/OptumHealth Behavioral
a UBH/OptumHealth Behavioral Solutions clinician         Solutions only to the minimum extent necessary
can make the appointment for you.                        to administer and manage the care provided when
                                                         you use your EAP, mental health and substance
Routine Care                                             abuse benefits, and in accordance with state and
                                                         federal laws. All of your records, correspondence,
Routine care is for conditions that present no           claims and conversations with UBH/OptumHealth
serious risk, and are not in danger of becoming an       Behavioral Solutions staff are kept completely
emergency. For routine care, in-network providers will   confidential in accordance with federal and state
have appointments to see you within three days of        laws. No information may be released to your
your initial call to UBH/OptumHealth Behavioral          supervisor, employer or family without your written
Solutions. If you need assistance with scheduling        permission, and no one will be notified when you
an appointment with an in-network provider,              use your EAP, mental health and substance abuse
a UBH/OptumHealth Behavioral Solutions clinician         benefits. UBH/OptumHealth Behavioral Solutions
can make the appointment for you.                        staff must comply with a strict confidentiality policy.

Enrollee Assistance Program (EAP)                        Complaints
Your EAP benefit provides access to a range of           If you are not satisfied with any aspect of the UBH/
resources, as well as focused, confidential, short-      OptumHealth Behavioral Solutions program, we
term counseling to treat problems of daily living        encourage you to call UBH/OptumHealth Behavioral
(e.g., emotional, marital or family problems, legal      Solutions at 1-888-610-9039 (TDD: 1-800-842-9489)
disputes, or financial difficulties). The EAP benefit    to speak with a customer service representative.
provides counseling and other professional               The UBH/OptumHealth Behavioral Solutions
services to you and your family members who are          member services representative resolves most
experiencing problems that can disrupt your              inquiries during your initial call. Inquiries that
personal and professional lives (e.g., international     require further research are reviewed by
events, community trauma). The EAP can also              representatives of the appropriate departments at
provide critical incident response and on-site           UBH/OptumHealth Behavioral Solutions, including
behavioral health consultation for state agencies        clinicians, claims representatives, administrators
and municipalities.                                      and other management staff who report directly
                                                         to senior corporate officers. We will respond to
                                                         all inquiries within three business days. Your
                                                         comments will help us correct any problems and
                                                         provide better service to you and your dependents.




Words in italics are defined in Part II.



82
Mental Health, Substance Abuse and Enrollee Assistance Programs


If the resolution of your inquiry is unsatisfactory      Written requests should be submitted to the
to you, you have the right to file a formal complaint    following address:
in writing within 60 days of the date of our telephone
                                                         United Behavioral Health/
call or letter of response. Please specify dates
                                                           OptumHealth Behavioral Solutions
of service and additional contact with UBH/
                                                         Appeals Department
OptumHealth Behavioral Solutions, and include any
                                                         100 East Penn Square
information you feel is relevant. Formal complaints
                                                         Suite 400
will be responded to in writing within 30 days.
                                                         Philadelphia, PA 19107
A formal complaint should be sent to the
                                                         Toll-Free Telephone: 1-877-447-6002, ext. 39291
following address:
                                                         Fax Number: 1-888-881-7453
United Behavioral Health
                                                         Appeal requests must include:
Complaint Unit
100 East Penn Square                                     •	 The member’s name and the identification
Suite 400                                                   number from the ID card
Philadelphia, PA 19107
                                                         •	 The date(s) of service(s)

Appeals                                                  •	 The provider’s name

Your Right to an Internal Appeal                         •	 The reason you believe the claim should be paid
You, your treating provider or someone acting on         •	 Any documentation or other written information
your behalf has the right to request an appeal of           to support your request for claim payment
the benefit decision made by UBH/OptumHealth
Behavioral Solutions. You may request an appeal          The Appeal Review Process (Non-Urgent Appeal)
in writing by following the steps below.                 •	 If you request an appeal review, the review will
                                                            be conducted by someone who was not involved
Note: If your care needs are urgent (meaning that           in the initial coverage denial, and who is not a
a delay in making a treatment decision could                subordinate to the person who issued the initial
significantly increase the risk to your health, could       coverage denial.
result in severe pain or could affect your ability
to regain maximum function), please see the              •	 For a non-urgent review of a denial of coverage,
section titled “How to Initiate an Urgently Needed          a UBH clinician will review the denial decision
Determination (Urgent Appeal)” on page 84.                  and will notify you of the decision in writing
                                                            within 15 calendar days of your request.
How to Initiate a First Level Internal Appeal
(Non-Urgent Appeal)                                      •	 For a review of a denial of coverage that already
Your appeal request must be submitted to us within          has been provided to you, we will review the
180 calendar days of your receipt of the notice of the      denial and will notify you in writing of UBH/
coverage denial.                                            BehavioralHealth Solutions’ decision within
                                                            30 calendar days of your request.




Words in italics are defined in Part II.



                                                                                                                83
Mental Health, Substance Abuse and Enrollee Assistance Programs


•	 If we exceed the time requirements for making      •	 Your provider’s name.
   a determination and providing notice of the
                                                      •	 Any information you would like to have
   decision, you may bypass our internal review
                                                         considered, such as records related to the current
   process and request a review by an independent
                                                         conditions of treatment, co-existent conditions
   third party.
                                                         or any other relevant information you believe
•	 If we continue to deny the payment, coverage or       supports your appeal.
   service requested, you may request an external
                                                      If you request an independent external review
   review by an independent third party, who will
                                                      we will complete a preliminary review within
   review your case and make a final decision.
                                                      five (5) business days to determine if your request
   This process is outlined in the “Independent
                                                      is complete and is eligible for an independent
   External Review Process (Non-Urgent Appeal)”
                                                      external review.
   section, below.
                                                      Additional information about this process along
Independent External Review Process
                                                      with your member rights and appeal information is
(Non-Urgent Appeal)                                   available at www.liveandworkwell.com, under GIC
You have a right to request an external review by     access 10910 or by speaking with a UBH/
an Independent Review Organization (IRO) of a         OptumHealth Behavioral Solutions’ representative.
decision made to not provide you a benefit or pay
for an item or service (in whole or in part). UBH/    How to Initiate an Urgently Needed
OptumHealth Behavioral Solutions is required by       Determination (Urgent Appeal)
law to accept the determination of the IRO in this    If you believe your situation is urgent, contact us
external review process.                              immediately to request an urgent review. If your
                                                      situation meets the definition of urgent under the
Requests can be made by you, your provider or
                                                      law, the review will be conducted on an expedited
someone you consent to act for you (your authorized
                                                      basis. Generally, an urgent situation is one in
representative). Requests must be made in writing
                                                      which your health may be in serious jeopardy
within 180 calendar days of receipt of your non-
                                                      or, if in the opinion of your physician, you may
coverage determination notice.
                                                      experience pain that cannot be adequately
Written requests for independent external review      controlled while you wait for a decision.
should be submitted to the following address:
                                                      •	 If you are requesting an urgent review, you may also
United Behavioral Health/                                request that a separate urgent review be conducted
  OptumHealth Behavioral Solutions                       at the same time by an independent third party.
Appeals Department                                       You, your provider or someone you consent to act
100 East Penn Square                                     for you (your authorized representative) may
Suite 400                                                request a review. Contact us if you would like to
Philadelphia, PA 19107                                   name an authorized representative on your behalf
Toll-Free Telephone: 1-877-447-6002, ext. 39291          to request a review of the decision.
Fax Number: 1-888-881-7453
                                                      •	 For an urgent review, we will make a determination
Independent External Review requests                     and will notify you verbally and in writing within
must include:                                            72 hours of your request. If we continue to deny
                                                         the payment, coverage or service requested, you
•	 Your name and identification number.
•	 The dates of service that were denied.


Words in italics are defined in Part II.



84
Mental Health, Substance Abuse and Enrollee Assistance Programs


  may request an external review by an independent    •	 Any information you would like to have
  third party, which will review your case and make      considered, such as records related to the current
  a final decision. This process is outlined in          conditions of treatment, co-existent conditions or
  the “Independent External Review Process               any other relevant information.
  (Urgent Appeal)” section, below.
                                                      If you request an independent external review
Independent External Review Process                   we will complete a preliminary review immediately
(Urgent Appeal)                                       for an urgent request to determine if your request
You have a right to request an external review by     is complete and is eligible for an independent
an Independent Review Organization (IRO) of           external review.
a decision made to not provide you a benefit or       Additional information about this process along
pay for an item or service (in whole or in part).     with your member rights and appeal information
UBH/OptumHealth Behavioral Solutions is               is available at www.liveandworkwell.com, under
required by law to accept the determination of        GIC access 10910 or by speaking with a UBH/
the IRO in this external review process.              OptumHealth Behavioral Solutions’ representative.
Requests can be made by you, your provider or
someone you consent to act for you (your authorized   Filing Claims
representative). Requests must be made in writing
                                                      In-network providers and facilities will file your
within 180 calendar days of receipt of your
                                                      claim for you. You are financially responsible for
noncoverage determination notice.
                                                      deductibles and copayments.
Written requests for independent external review
                                                      Out-of-network providers are not required to process
should be submitted to the following address:
                                                      claims on your behalf; you must submit the claims
United Behavioral Health/                             yourself. You are responsible for all coinsurance
  OptumHealth Behavioral Solutions                    and deductibles. Send the out-of-network provider’s
Appeals Department                                    itemized bill and a completed CMS 1500 claim
100 East Penn Square                                  form, with your name, address and GIC ID number
Suite 400                                             to the following address:
Philadelphia, PA 19107
                                                      United Behavioral Health/
Toll-Free Telephone: 1-877-447-6002, ext. 39291
                                                        OptumHealth Behavioral Solutions
Fax Number: 1-888-881-7453
                                                      Claims
Independent External Review requests must include:    P.O. Box 30755
                                                      Salt Lake City, UT 84130-0755
•	 Your name and identification number.
                                                      The CMS 1500 form is available from your provider.
•	 The dates of service that were denied.
                                                      Claims must be received by UBH/OptumHealth
•	 Your provider’s name.                              Behavioral Solutions within 15 months of the date
                                                      of service for you or a covered dependent. You must
                                                      have been eligible for coverage on the date you
                                                      received care. All claims are confidential.




Words in italics are defined in Part II.



                                                                                                           85
Mental Health, Substance Abuse and Enrollee Assistance Programs


Coordination of Benefits                             For More Information
All benefits under this plan are subject to          UBH/OptumHealth Behavioral Solutions customer
coordination of benefits, which determines whether   service staff is available to help you. Call
your mental health and substance abuse care is       1-888-610-9039 (TDD: 1-800-842-9489) for assistance
partially or fully covered by another plan. UBH/     Monday through Friday, from 9 a.m. to 8 p.m.
OptumHealth Behavioral Solutions may request         Eastern Time.
information from you about other health insurance
coverage in order to process your claim correctly.




Words in italics are defined in Part II.



86
Mental Health, Substance Abuse and Enrollee Assistance Programs


  Part II – Benefit Highlights
Definitions of UBH/OptumHealth                             Coordination of Benefits (COB) – A methodology
                                                           that determines the order and proportion of
Behavioral Solutions Terms                                 insurance payment when a member has coverage
Allowed Charges – The amount that UBH/                     through more than one insurer. The regulations
OptumHealth Behavioral Solutions determines to             define which organization has primary responsibility
be within the range of payments most often made            for payment and which organization has secondary
to similar providers for the same service or supply.       responsibility for any remaining charges not
If the cost of treatment for out-of-network care           covered by the primary plan.
exceeds the allowed charges, the member may be
                                                           Copayment (copay) – A fixed dollar amount that
responsible for the cost difference.
                                                           a member must pay out of his or her own pocket.
Appeal – A formal request for UBH/OptumHealth
                                                           Covered Services – Services and supplies provided
Behavioral Solutions to reconsider any adverse
                                                           for the purpose of preventing, diagnosing or treating
determination or denial of coverage, either
                                                           a behavioral disorder, psychological injury or
concurrently or retrospectively, for admissions,
                                                           substance abuse addiction, and that are described
continued stays, levels of care, procedures or services.
                                                           in the section titled “What This Plan Pays,” and not
Case Management – A UBH/OptumHealth                        excluded under the section titled “What’s Not
Behavioral Solutions clinical case manager will            Covered – Exclusions.”
review cases using objective clinical criteria to
                                                           Cross-Accumulation – The sum of applicable medical
determine the appropriate treatment that is
                                                           and behavioral health expenses paid by a member to
a service covered by the plan of benefits for
                                                           determine whether a member’s deductible or out-of-
a covered diagnostic condition.
                                                           pocket maximum has been reached.
Coinsurance – The amount you pay for certain
                                                           Deductible – The designated amount that a member
services under UBH/OptumHealth Behavioral
                                                           must pay for any charges before insurance
Solutions. The amount of coinsurance is a percentage
                                                           coverage applies.
of the total amount for the service; the remaining
percentage is paid by UBH/OptumHealth Behavioral           Intermediate Care – Care that is more intensive than
Solutions. The provider is responsible for billing the     traditional outpatient treatment but less intensive
member for the remaining percentage.                       than 24-hour hospitalization. Some examples
                                                           include but are not limited to residential treatment,
Complaint – A verbal or written statement of
                                                           group homes, halfway houses, therapeutic foster
dissatisfaction arising from a perceived adverse
                                                           care, day or partial hospital programs, or structured
administrative action, decision or policy by UBH/
                                                           outpatient programs.
OptumHealth Behavioral Solutions.
                                                           In-network Provider – A provider who participates
Continuing review or concurrent review –
                                                           in the UBH/OptumHealth Behavioral Solutions
A clinical case manager’s periodic assessment of
                                                           network.
a member’s care while it is being delivered, the
proposed treatment plan for future care, and               Member – An individual who is enrolled in the
the appropriateness of continued care.                     Group Insurance Commission’s UniCare State
                                                           Indemnity Plan/Community Choice.



Words in italics are defined in Part II.



                                                                                                               87
Mental Health, Substance Abuse and Enrollee Assistance Programs


Non-Notification Penalty – The amount charged            Pre-authorization – The process of obtaining
when you fail to pre-certify care. It does not count     authorization for services with UBH/OptumHealth
toward the out-of-pocket maximum.                        Behavioral Solutions prior to seeking Enrollee
                                                         Assistance Program (EAP), mental health and
Non-Routine – A service that is not customary.
                                                         substance abuse care. All pre-authorization is
The following services are considered non-routine
                                                         performed by UBH/OptumHealth Behavioral
and require pre-authorization: intensive outpatient
                                                         Solutions clinicians.
treatment programs, outpatient electroconvulsive
treatment (ECT), psychological testing, methadone        Pre-certification (Pre-certify) – The process of
maintenance, extended outpatient treatment               registering for services with UBH/OptumHealth
visits that go beyond 45 to 50 minutes in duration       Behavioral Solutions prior to seeking Enrollee
with or without medication management,                   Assistance Program (EAP), mental health and
Applied Behavioral Analysis (ABA).                       substance abuse care. All pre-certification is
                                                         performed by UBH/OptumHealth Behavioral
Out-of-Network Provider – A provider who does not
                                                         Solutions clinicians.
participate in the UBH/OptumHealth Behavioral
Solutions network.                                       Routine Services – A customary or regular service,
                                                         such as: individual sessions, group therapy of
Out-of-Pocket Maximum – The maximum amount
                                                         45 to 50 minutes in duration and medication
you will pay in coinsurance and copayments for your
                                                         management.
mental health and substance abuse care in one
calendar year. When you have met your out-of-pocket      UBH/OptumHealth Behavioral Solutions Clinician –
maximum, all care will be covered at 100 percent         A staff member who pre-certifies EAP, mental health
of the allowed charge until the end of that calendar     and substance abuse services. UBH/OptumHealth
year. This maximum does not include non-notification     Behavioral Solutions clinicians have the following
penalties, charges for out-of-network care that exceed   qualifications: a master’s degree in psychology,
the maximum number of covered days or visits,            social work or a related field; three or more years of
out-of-network out-of-pocket outpatient coinsurance,     clinical experience; Certified Employee Assistance
the out-of-network calendar year deductible, charges     Professionals (CEAP) certification or eligibility; and
for care not deemed to be a covered service, and         a comprehensive understanding of the full range
charges in excess of UBH/OptumHealth Behavioral          of EAP services for employees and employers,
Solutions allowed charges.                               including workplace and personal concerns.




Words in italics are defined in Part II.



88
Mental Health, Substance Abuse and Enrollee Assistance Programs


What This Plan Pays                                       The Plan also covers the following services:

The Plan pays for the following services:                 •	 Enrollee Assistance Program – Short-term
                                                             counseling or other services that focus on
•	 Outpatient Care – Individual or group sessions            problems of daily living, such as marital problems,
   with a therapist, usually conducted once a week,          conflicts at work, legal or financial difficulties,
   in the provider’s office or facility.                     and dependent care needs.
•	 Intermediate Care – Care that is more intensive        •	 www.liveandworkwell.com – An interactive
   than traditional outpatient services but less             website offering a large collection of wellness
   intensive than 24-hour hospitalization. Some              articles, service databases including a UBH/
   examples include but are not limited to:                  OptumHealth Behavioral Solutions Massachusetts
   residential treatment, group homes, halfway               in-network provider directory, tools, financial
   houses, day or partial hospitals, or structured           calculators and expert chats. To enter the site,
   outpatient programs.                                      log on to www.liveandworkwell.com and enter
•	 In-Home Care – A licensed mental health                   access code 10910.
   professional visits the patient in his or her home.    These services are subject to certain exclusions,
•	 Inpatient Care – Treatment in a hospital or            which are found in Part III.
   substance abuse facility.
•	 Detoxification – Medically supervised withdrawal
   from an addictive chemical substance, which may
   be done in a substance abuse facility.
•	 Drug Testing – Pre-certified drug testing is covered
   as an adjunct to substance abuse treatment.
•	 Autism Spectrum Disorders – Medically
   necessary services provided for the diagnosis and
   treatment of autism spectrum disorders pursuant
   to the requirements of your plan and to the extent
   of the requirements of Massachusetts law.




Words in italics are defined in Part II.



                                                                                                              89
Mental Health, Substance Abuse and Enrollee Assistance Programs


Benefits Chart
The following chart outlines certain benefits available to you. Be sure to read Part III, which describes your
benefits in detail and includes some important restrictions. For assistance, call 24 hours a day, seven days a
week: 1-888-610-9039 (TDD: 1-800-842-9489).

 Covered Services                          Network Benefits                    Out-of-Network Benefits
 Calendar Year Deductible                  None                                Deductible is shared with your
                                                                               medical benefit calendar year
                                                                               deductible: $250 per individual;
                                                                               up to a maximum of $750
                                                                               per family. (a)
 Out-of-Pocket Maximum                     $1,000 per individual               $3,000 per member;
                                           $2,000 per family                   no family maximum
 Benefit Maximums                          Unlimited                           Unlimited
 Inpatient Care
 Mental Health
     General hospital                      100%, after inpatient care copay    $200 copay per quarter after
     Psychiatric hospital                  of: $200 per calendar quarter       meeting the calendar year
                                                                               deductible; 100% covered
                                                                               thereafter
 Substance Abuse
     General hospital or                   100%, after inpatient care copay    $200 copay per quarter after
     substance abuse facility              of: $200 per calendar quarter       meeting the calendar year
                                                                               deductible; 100% covered
                                                                               thereafter
                                           All inpatient, intermediate and hospital care must be pre-certified.
                                           Emergency admissions must be pre-authorized within 24 hours
                                           to receive maximum benefits. A $500 non-notification penalty does
                                           not count toward out-of-pocket maximums.




Words in italics are defined in Part II.



90
Mental Health, Substance Abuse and Enrollee Assistance Programs


 Covered Services                             Network Benefits                             Out-of-Network Benefits
 Intermediate Care
 (Care that is more intensive than            100%, after inpatient care copay             $200 copay per quarter after
 traditional outpatient services              of: $200 per calendar quarter                meeting the calendar year
 but less intensive than 24-hour                                                           deductible; 100% covered
 hospitalization. Examples are                                                             thereafter
 residential treatment, group
 homes, halfway houses, day or
 partial hospitals, or structured
 outpatient programs.)
 Outpatient Care (b), (c) – Mental Health, Substance Abuse and Enrollee Assistance Program (EAP)
 Enrollee Assistance Program                  Up to 3 visits: 100% per member,             No coverage for EAP
 (EAP)                                        per problem, per calendar year
                                              EAP non-notification penalty reduces benefit to zero: no benefits
                                              paid. EAP sessions are based on per member, per problem, per
                                              calendar year.
 Individual and Family Therapy                100%, after $20 per visit copay              100%, after $30 per visit copay
 Autism Spectrum                              100%, after $20 per visit copay              100%, $30 copay per visit
 Disorder Services
 Group Therapy                                100%, after $15 per visit copay              100%, after $30 per visit copay
 Medication Management:                       100%, after $15 per visit copay              100%, after $30 per visit copay
 (15- to 30-minute
 psychiatrist visit)
 In-Home Mental Health Care                   100% coverage                                100%, after $30 per visit copay
 Drug Testing (as an adjunct to               100% coverage                                No coverage
 substance abuse treatment)
                                              Non-notification penalty for outpatient services reduces benefit to
                                              zero: no benefits paid.
 Provider Eligibility (provider               MD psychiatrist, PhD, PsyD,                  MD psychiatrist, PhD, PsyD,
 must be licensed in one of                   EdD,	MSW,	BCBA,	MSN,	                        EdD, MSW, MSN, LICSW,
 these disciplines)                           LICSW, RNMSCS, MA (c)                        BCBA,	RNMSCS,	MA	(c)
(a) Cross-accumulates with all out-of-network mental health and substance abuse benefit and medical service levels.
(b) Pre-certification is required for the following outpatient services: intensive outpatient program treatment, outpatient
    electroconvulsive treatment, psychological testing, extended outpatient visits beyond 50 minutes with or without medication,
    Applied	Behavioral	Analysis	(ABA),	methadone	maintenance.
(c) Massachusetts independently licensed providers: psychiatrists, psychologists, licensed clinical social workers, psychiatric nurse
    clinical specialists, board certified behavioral analysts and allied mental health professionals.
Please note: The words in italics have special meanings that are given in the glossary.




Words in italics are defined in Part II.



                                                                                                                                   91
Mental Health, Substance Abuse and Enrollee Assistance Programs


  Part III — Benefits Explained
Mental Health and Substance                                Group therapy,               $15 copayment
                                                           all visits
Abuse Benefits
                                                           Enrollee Assistance          No copayment
In-Network Services                                        Program, up to 3 visits
In order to receive maximum network benefits for
Enrollee Assistance Program (EAP), mental health          Failure to pre-certify non-routine outpatient care
and substance abuse treatment, it is recommended          results in a benefit reduction to the out-of-network
you call UBH/OptumHealth Behavioral Solutions             level reimbursement, and in some cases, it may
at 1-888-610-9039 (TDD: 1-800-842-9489) to                result in no coverage. Routine services do not
pre-certify non-routine care and obtain a referral        require pre-certification.
to an in-network provider.
                                                          Routine Services – Individual sessions, group
Pre-certified in-network care has no deductible.          therapy of 45 to 50 minutes in duration and
Covered services are paid at 100 percent after the        medication management are considered
appropriate copayments (see copayment schedule            routine services.
below). The calendar year out-of-pocket maximum
for in-network services is $1,000 per individual          Non-Routine – The following services are considered
and $2,000 per family.                                    non-routine and require pre-authorization: Intensive
                                                          Outpatient Treatment Programs, Outpatient
The following do not count toward the                     Electroconvulsive Treatment (ECT), Psychological
out-of-pocket maximum:                                    Testing, Extended outpatient treatment visits that go
1. Non-notification penalties                             beyond 45 to 50 minutes in duration with or without
2. Cost of treatment subject to exclusions                medication management, Applied Behavioral
                                                          Analysis (ABA).
If you fail to obtain pre-certification for non-routine
care, you will be charged a non-notification penalty.     In-Home Care – In-home care is a covered service at
The non-notification penalty for each type of service     100% if pre-certified. Treatment that is not pre-certified
is listed in the Benefits Chart on pages 90-91,           but deemed to be a covered service receives out-of-
and in the following descriptions of services.            network-level reimbursement, but in some cases, it
                                                          may result in no coverage. Please refer to the section
In-Network Benefits                                       titled “Out-of-Network Services” for details.
Outpatient Care – The copayment schedule for
in-network outpatient covered services is                 Intermediate Care – In-network intermediate care
shown below:                                              deemed to be a covered service in a general or
                                                          psychiatric hospital or in a substance abuse facility,
 Individual and family              $20 copayment         if pre-certified, is covered at 100 percent after
 therapy, all visits                                      $200 copay per calendar quarter. The copay is waived
                                                          if re-admitted within 30 days with a maximum
 Autism Spectrum                    $20 copayment
 Disorder Outpatient                                      of one copay per calendar quarter. There is a $500
 visit, all visits                                        non-notification penalty for failure to pre-certify
                                                          inpatient care.
 Medication                         $15 copayment
 management, all visits


Words in italics are defined in Part II.



92
Mental Health, Substance Abuse and Enrollee Assistance Programs


Inpatient Care – In-network inpatient care deemed to        •	 Treatment planning conducted by a BCBA
be a covered service in a general or psychiatric hospital      (or qualified licensed clinician)
or in a substance abuse facility, if pre-certified, is
                                                            •	 Direct ABA services by a BCBA or
covered at 100 percent after $200 copay per calendar
                                                               licensed clinician
quarter. The copay is waived if re-admitted within
30 days with a maximum of one copay per calendar            •	 Direct ABA services by a paraprofessional
quarter. There is a $500 non-notification penalty for          or BCBA (if appropriately supervised)
failure to pre-certify inpatient care.
                                                            Psychiatric Services – Psychiatric services for Autism
Drug Testing – Pre-certified drug testing is covered as     Spectrum Disorders that are provided by, or under
an adjunct to substance abuse treatment.                    the direction of, an experienced psychiatrist and/or
                                                            an experienced licensed psychiatric provider and
Autism Spectrum Disorders – The plan will cover
                                                            are focused on treating maladaptive/stereotypic
medically necessary services provided for the
                                                            behaviors that are posing danger to self, others
diagnosis and treatment of autism spectrum disorders
                                                            and property, and impairment in daily
pursuant to the requirements of the plan and to the
                                                            functioning include:
extent of the requirements of Massachusetts law,
including without limitation:                               •	 Diagnostic evaluations and assessment
•	 Professional services by providers – including care      •	 Treatment planning
   by appropriately credentialed, licensed or certified
                                                            •	 Referral services
   psychiatrists, psychologists, social workers, and
   board certified behavior analysts.                       •	 Medication management
•	 Habilitative and rehabilitative care, including, but     •	 Inpatient/24-hour supervisory care
   not limited to, applied behavioral analysis by a
                                                            •	 Partial Hospitalization/Day Treatment
   board certified behavior analyst as defined by law.
                                                            •	 Intensive Outpatient Treatment
Applied Behavioral Analysis Services (ABA) –
Services related to ABA (listed below) based on             •	 Services at a Residential Treatment Facility
medical necessity and managed under UBH/
                                                            •	 Individual, family, therapeutic group, and
OptumHealth Behavioral Solutions level of care
                                                               provider-based case management services
guidelines. Services must be provided by, or under
the direction of, an experienced psychiatrist and/or        •	 Psychotherapy, consultation, and training session
an experienced licensed psychiatric provider or                for parents and paraprofessional and resource
conjoint supervision of paraprofessionals by                   support to family
a BCBA (or qualified licensed clinician) and
                                                            •	 Crisis Intervention
include the following:
                                                            •	 Transitional Care
•	 Skills Assessment by BCBA or qualified
   licensed clinician
•	 Conjoint Supervision of Paraprofessionals by
   BCBA (or qualified licensed clinician) with
   clients present




Words in italics are defined in Part II.



                                                                                                                93
Mental Health, Substance Abuse and Enrollee Assistance Programs


Additional Autism Spectrum Disorder                         clinician will refer you to a trained EAP provider
coverage information is available online at                 and/or other specialized resource (e.g., attorney,
www.liveandworkwell.com under GIC access code               family mediator, dependent care service) in your
10910 or by speaking with a UBH/OptumHealth                 community. The UBH/OptumHealth Behavioral
Behavioral Solutions Autism Care Advocate                   Solutions clinician may recommend mental health
at 1-888-610-9039 (TDD: 1-800-842-9489).                    and substance abuse services if the problem
                                                            seems to require help that is more extensive than
Psychological Testing – Psychological testing,
                                                            EAP services can provide.
including neuropsychological testing for a mental
health condition that is deemed to be a covered
service is covered when pre-certified. Psychological        Legal Services
testing that is not pre-certified, yet deemed to be         In addition to EAP counseling, legal assistance is
a covered service, receives out-of-network-level            available to enrollees of the UniCare State
reimbursement if deemed to be a covered service.            Indemnity Plan/Community Choice. The UBH/
It is highly recommended that you obtain                    OptumHealth Behavioral Solutions Legal Assistance
pre-certification before initiating psychological testing   services give you free and discounted confidential
in order to confirm the extent of your coverage.            access to a local attorney, who will answer legal
(Guidelines for coverage of psychological testing           questions, prepare legal documents and help solve
are listed on the UBH/OptumHealth Behavioral                legal issues. These services are provided:
Solutions website.) Please note that neuro-
psychological testing for a medical condition is            •	 Free referral to a local attorney
covered under the medical component of your plan.           •	 Free 30-minute consultation (phone or in-person)
                                                               per legal matter
Enrollee Assistance Program (EAP)                           •	 25% discount for ongoing services
The EAP can help with the following types
                                                            •	 Free online legal information, including common
of problems:
                                                               forms and wills kits
1.    Breakup of a relationship
                                                            For more information or to be connected with
2.    Divorce or separation
                                                            UBH/OptumHealth Behavioral Solutions
3.    Becoming a stepparent
                                                            Legal Assistance, call UBH/OptumHealth
4.    Helping children adjust to new family members
                                                            Behavioral Solutions toll-free at
5.    Death of a friend or family member
                                                            1-888-610-9039 (TDD: 1-800-842-9489).
6.    Communication problems
7.    Conflicts in relationships at work
8.    Legal difficulties                                    Employee Assistance Program
9.    Financial difficulties                                The Commonwealth’s Group Insurance
10.   Childcare or eldercare needs                          Commission also offers an Employee Assistance
11.   Aging                                                 Program to all agencies and municipalities.
12.   Traumatic events                                      Managers and supervisors can receive confidential
To use your EAP benefit, call 1-888-610-9039 (TDD:          consultations and resource recommendations for
1-800-842-9489). The procedures for pre-certifying          dealing with employee problems such as low
EAP care and referral to an EAP provider are the            morale, disruptive workplace behavior, mental
same as for mental health and substance abuse               illness and substance abuse.
services. A UBH/OptumHealth Behavioral Solutions


Words in italics are defined in Part II.



94
Mental Health, Substance Abuse and Enrollee Assistance Programs


Autism Spectrum Disorders                                 All out-of-network non-routine care must be pre-certified
                                                          with UBH/OptumHealth Behavioral Solutions in
The plan will cover medically necessary services          order to be eligible for coverage. All out-of-network
provided for the diagnosis and treatment of autism        outpatient visits in a calendar year – including
spectrum disorders pursuant to the requirements           mental health, substance abuse and EAP outpatient
of the plan and the requirements and extent of            visits, medication management visits, and in-home
Massachusetts law, including without limitation:          mental health care visits – are accumulated to
•	 Professional services by providers – including         determine the appropriate out-of-network level of
   care by appropriately credentialed, licensed or        reimbursement. Charges paid by the member for
   certified psychiatrists, psychologists, social         out-of-network outpatient care, if determined to be
   workers, and board certified behavior analysts.        a covered service and if pre-certified when required,
                                                          do count toward the out-of-pocket maximum. If it
•	 Habilitative and rehabilitative care, including, but   is determined that care was not a covered service,
   not limited to, applied Behavioral analysis by a       no benefits will be paid.
   board certified behavior analyst as defined by law.
                                                          Out-of-Network Benefits
Out-of-Network Services
                                                          Outpatient Care – Outpatient visits deemed to be
Care from an out-of-network provider is paid at a         a covered service are paid at 100 percent after
lower level than in-network care. Out-of-network care     $30 copay per visit.
is subject to deductibles, copayments and coinsurance.
                                                          In-Home Care – In-Home Care visits deemed to
Benefits are paid based on allowed charges, which are     be a covered service are paid at 100 percent after
UBH/OptumHealth Behavioral Solutions reasonable           $30 copay per visit.
and customary fees or negotiated fee maximums.
If your out-of-network provider or facility charges       Intermediate Care – Intermediate care deemed to be
more than these allowed charges, you may be               a covered service is paid at $200 copay per quarter
responsible for the difference, in addition to any        after meeting the calendar year deductible; 100%
amount not covered by the benefit.                        covered thereafter.

Out-of-network mental health and substance abuse          Inpatient Care – Out-of-network inpatient care
treatment is subject to a $250 per person or $750         deemed to be a covered service for mental health
per family calendar year deductible. Calendar year        care or substance abuse treatment is paid at
deductibles must be met prior to inpatient copays.        $200 copay per quarter after meeting the calendar
                                                          year deductible; 100% covered thereafter in
The out-of-pocket maximum for out-of-network care         a general hospital, psychiatric facility or substance
is $3,000 per person. The following do not count          abuse facility.
toward the out-of-pocket maximum:
                                                          Each admission to a hospital or facility is subject
•	 Out-of-network calendar year deductibles               to $200 copay per quarter per person in addition to
•	 Out-of-network inpatient copays                        the calendar year deductible. Failure to pre-certify
                                                          inpatient care is subject to a non-notification penalty
•	 Non-notification penalties                             of $500 if the UBH/OptumHealth Behavioral
•	 Cost of treatment found to not be a covered service    Solutions case manager determines that the care
                                                          is a covered service. No benefits will be paid if it
•	 Charges in excess of UBH/OptumHealth                   was found not to be a covered service.
   Behavioral Solutions allowed charges

Words in italics are defined in Part II.



                                                                                                                  95
Mental Health, Substance Abuse and Enrollee Assistance Programs


Drug Testing – There is no coverage for out-of-           Psychiatric Services – Psychiatric services for
network drug testing.                                     Autism Spectrum Disorders that are provided by,
                                                          or under the direction of, an experienced
Autism Spectrum Disorders – The plan will cover
                                                          psychiatrist and/or an experienced licensed
medically necessary services provided for the
                                                          psychiatric provider and are focused on treating
diagnosis and treatment of autism spectrum
                                                          maladaptive/stereotypic behaviors that are posing
disorders, pursuant to the requirements of the
                                                          danger to self, others and property, and impairment
plan and to the extent of the requirements of
                                                          in daily functioning include:
Massachusetts law, including without limitation:
                                                          •	 Diagnostic evaluations and assessment
•	 Professional services by providers – including
   care by appropriately credentialed, licensed or        •	 Treatment planning
   certified psychiatrists, psychologists, social
                                                          •	 Referral services
   workers, and board certified behavior analysts.
                                                          •	 Medication management
•	 Habilitative and rehabilitative care, including, but
   not limited to, applied behavioral analysis by a       •	 Inpatient/24-hour supervisory care
   board certified behavior analyst as defined by law.
                                                          •	 Partial Hospitalization/Day Treatment
Applied Behavioral Analysis Services (ABA) –
                                                          •	 Intensive Outpatient Treatment
Services related to ABA (listed below) based on
medical necessity and managed under UBH/                  •	 Services at a Residential Treatment Facility
OptumHealth Behavioral Solutions level of care
                                                          •	 Individual, family, therapeutic group, and
guidelines. Services must be provided by, or under
                                                             provider-based case management services
the direction of, an experienced psychiatrist and/or
an experienced licensed psychiatric provider or           •	 Psychotherapy, consultation, and training session
conjoint supervision of paraprofessionals by                 for parents and paraprofessional and resource
a BCBA (or qualified licensed clinician) and                 support to family
include the following:
                                                          •	 Crisis Intervention
•	 Skills Assessment by BCBA or qualified
                                                          •	 Transitional Care
   licensed clinician
                                                          Additional Autism Spectrum Disorder
•	 Conjoint Supervision of Paraprofessionals
                                                          coverage information is available online at
   by BCBA (or qualified licensed clinician) with
                                                          www.liveandworkwell.com under GIC access code
   clients present
                                                          10910 or by speaking with a UBH/OptumHealth
•	 Treatment planning conducted by a BCBA                 Behavioral Solutions Autism Care Advocate
   (or qualified licensed clinician)                      at 1-888-610-9039 (TDD: 1-800-842-9489).
•	 Direct ABA services by a BCBA or                       Enrollee Assistance Program – There is no coverage
   licensed clinician                                     for out-of-network EAP services.
•	 Direct ABA services by a paraprofessional or
   BCBA (if appropriately supervised)




Words in italics are defined in Part II.



96
Mental Health, Substance Abuse and Enrollee Assistance Programs


What’s Not Covered – Exclusions                           − UBH/OptumHealth Behavioral Solutions may
                                                            consult with professional clinical consultants,
The following exclusions apply regardless of whether        peer review committees or other appropriate
the services, supplies or treatment described in this       sources for recommendations and information.
section are recommended or prescribed by the
member’s provider and/or are the only available         •	 Services, supplies or treatments that are considered
treatment options for the member’s condition.              unproven, investigational, or experimental
                                                           because they do not meet generally accepted
This plan does not cover services, supplies or             standards of medical practice in the United States.
treatment relating to, arising out of or given in          The fact that a service, treatment or device is the
connection with the following:                             only available treatment for a particular condition
•	 Services performed in connection with conditions        will not result in it being a service if the service,
   not classified in the current edition of the            treatment or device is considered to be unproven,
   Diagnostic and Statistical Manual of Mental Health      investigational or experimental.
   Disorders (DSM)                                      •	 Custodial care, except for the acute stabilization of
•	 Prescription drugs or over-the-counter drugs and        the member, and returning the member back to
   treatments. (Refer to your prescription drug plan       his or her baseline level of individual functioning.
   for benefit information.)                               Care is determined to be custodial when it provides
                                                           a protected, controlled environment for the primary
•	 Services or supplies for Mental Health and              purpose of protective detention and/or providing
   Substance Abuse – A treatment that, in the              services necessary to ensure the member’s
   reasonable judgment of UBH/OptumHealth                  competent functioning in activities of daily living;
   Behavioral Solutions, fits any of the following         or when it is not expected that the care provided
   descriptions:                                           or psychiatric treatment alone will reduce the
  − Are not consistent with the symptoms and signs         disorder, injury or impairment to the extent
    of diagnosis and treatment of the behavioral           necessary for the member to function outside a
    disorder, psychological injury or substance abuse      structured environment. This applies to members
                                                           for whom there is little expectation of improve-
  − Are not consistent with prevailing national            ment in spite of any and all treatment attempts.
    standards of clinical practice for the treatment
    of such conditions                                  •	 Members whose repeated and volitional
                                                           non-compliance with treatment recommendations
  − Are not consistent with prevailing professional        results in a situation in which there can be no
    research demonstrating that the service or             reasonable expectation of a successful outcome.
    supplies will have a measurable and beneficial
    health outcome                                      •	 Neuropsychological testing for the diagnosis of
                                                           attention-deficit hyperactivity disorder. (Note:
  − Typically do not result in outcomes                    Neuropsychological testing for medical conditions
    demonstrably better than other available               is covered under the medical component of
    treatment alternatives that are less intensive         your plan.)
    or more cost effective; or that are consistent
    with the UBH/OptumHealth Behavioral
    Solutions Level of Care Guidelines or best
    practices as modified from time to time.




Words in italics are defined in Part II.



                                                                                                              97
Mental Health, Substance Abuse and Enrollee Assistance Programs


•	 Examinations or treatment, unless it otherwise        •	 Smoking cessation related services and supplies.
   qualifies as behavioral health services, when:
                                                         •	 Travel or transportation expenses, unless UBH/
  − Required solely for purposes of career,                 OptumHealth Behavioral Solutions has requested
    education, sports or camp, travel, employment,          and arranged for the member to be transferred by
    insurance, marriage, or adoption                        ambulance from one facility to another.
  − Ordered by a court except as required by law         •	 Services performed by a provider who is a family
                                                            member by birth or marriage, including spouse,
  − Conducted for purposes of medical research
                                                            brother, sister, parent or child. This includes
  − Required to obtain or maintain a license of             any service the provider may perform on himself
    any type                                                or herself.
•	 Herbal medicine, holistic or homeopathic care,        •	 Services performed by a provider with the same
   including herbal drugs or other forms of                 legal residence as the member.
   alternative treatment as defined by the Office of
                                                         •	 Mental health and substance abuse services for
   Alternative Medicine of the National Institutes
                                                            which the member has no legal responsibility to
   of Health.
                                                            pay, or for which a charge would not ordinarily be
•	 Nutritional counseling, except as prescribed for         made in the absence of coverage under the plan.
   the treatment of primary eating disorders as part
                                                         •	 Charges in excess of any specified plan
   of a comprehensive multimodal treatment plan.
                                                            limitations.
•	 Weight reduction or control programs (unless
                                                         •	 Any charges for missed appointments.
   there is a diagnosis of morbid obesity and the
   program is under medical supervision), special        •	 Any charges for record processing except as
   foods, food supplements, liquid diets, diet plans        required by law.
   or any related products or supplies.
                                                         •	 Services provided under another plan. Services
•	 Services or treatment rendered by unlicensed             or treatment for which other coverage is required
   providers, including pastoral counselors (except as      by federal, state or local law to be purchased or
   required by law), or services or treatment outside       provided through other arrangements. This
   the scope of a provider’s licensure.                     includes but is not limited to coverage required
                                                            by workers’ compensation, no-fault auto insurance
•	 Personal convenience or comfort items, including
                                                            or similar legislation. If a member could have
   but not limited to such items as TVs, telephones,
                                                            elected workers’ compensation or a similar law
   computers, beauty or barber services, exercise
                                                            (or could have it elected for him/her), benefits will
   equipment, air purifiers, or air conditioners.
                                                            not be paid.
•	 Light boxes and other equipment, including
                                                         •	 Treatment or services received prior to a member
   durable medical equipment, whether associated
                                                            being eligible for coverage under the plan or
   with a behavioral or non-behavioral condition.
                                                            after the date the member’s coverage under the
•	 Private duty nursing services while confined in          plan ends.
   a facility.
•	 Surgical procedures including but not limited to
   sex transformation operations.




Words in italics are defined in Part II.


98
                                            APPENDICES




               Appendix A: GIC Notices                  Appendix E: Claim Form
Appendix B: Disclosure when Plan Meets         Appendix F: Bill Checker Program
        Minimum Standards (for health
                                          Appendix G: Federal and State Mandates
   insurance coverage in Massachusetts)
                                                Appendix H: Your Right to Appeal
        Appendix C: Community Choice
                      Hospital Listing      Appendix I: Preventive Care Schedule
   Appendix D: Designated Hospitals for            Appendix J: Preferred Vendors
    Select Complex Inpatient Procedures
                     and Neonatal ICUs
                                                                             99
  Appendix A: GIC Notices
•	 Notice of Group Insurance Commission                   revised notices to the address you have supplied,
   Privacy Practices                                      and will post the updated notice on our website at
                                                          www.mass.gov/gic.
•	 Important Notice from the Group Insurance
   Commission (GIC) about Your Prescription               Required and Permitted Uses and Disclosures
   Drug Coverage and Medicare                             We use and disclose protected health information
                                                          (“PHI”) in a number of ways to carry out our
•	 Important Information from the Group Insurance
                                                          responsibilities. The following describes the types
   Commission about Your HIPAA Portability Rights
                                                          of uses and disclosures of PHI that federal law
•	 The Uniformed Services Employment and                  requires or permits the GIC to make without
   Reemployment Rights Act (USERRA)                       your authorization:
•	 Notice about the Federal Early Retiree                 Payment activities: The GIC may use and share
   Reinsurance Program                                    PHI for plan payment activities, such as paying
                                                          administrative fees for health care, paying health
                                                          care claims, and determining eligibility for
                                                          health benefits.
Notice of Group Insurance
Commission Privacy Practices                              Health Care Operations: The GIC may use and
                                                          share PHI to operate its programs that include
Effective February 17, 2010                               evaluating the quality of health care services you
THIS NOTICE DESCRIBES HOW MEDICAL                         receive, arranging for legal and auditing services
INFORMATION ABOUT YOU MAY BE USED                         (including fraud and abuse detection), and
AND DISCLOSED, AND HOW YOU CAN GET                        performing analyses to reduce health care costs
ACCESS TO THIS INFORMATION. PLEASE                        and improve plan performance.
REVIEW IT CAREFULLY.                                      To Provide You Information on Health-Related
By law, the GIC must protect the privacy of your          Programs or Products: Such information may include
personal health information. The GIC retains this         alternative medical treatments or programs about
type of information because you receive health            health-related products and services, subject to
benefits from the Group Insurance Commission.             limits imposed by law as of February 17, 2010.
Under federal law, your health information (known         Other Permitted Uses and Disclosures: The GIC
as “protected health information” or “PHI”) includes      may use and share PHI as follows:
what health plan you are enrolled in and the type of
health plan coverage you have. This notice explains       •	 To resolve complaints or inquiries made on your
your rights and our legal duties and privacy practices.      behalf (such as appeals);

The GIC will abide by the terms of this notice.           •	 To enable business associates that perform
Should our information practices materially change,          functions on our behalf or provide services, if the
the GIC reserves the right to change the terms of            information is necessary for such functions or
this notice, and must abide by the terms of the              services. Our business associates are required,
notice currently in effect. Any new notice provisions        under contract with us, to protect the privacy of
will affect all protected health information we already      your information and are not allowed to use or
maintain, as well as protected health information            disclose any information other than as specified
that we may receive in the future. We will mail              in our contract. As of February 17, 2010, our
                                                             business associates also will be directly subject
                                                             to federal privacy laws;

100
Appendix A


•	 For data breach notification purposes. We may        Your Rights
   use your contact information to provide legally-     You have the right to:
   required notices of unauthorized acquisition,
                                                        •	 Ask to see and get a copy of your PHI that the GIC
   access or disclosure of your health information;
                                                           maintains. You must ask for this in writing. Under
•	 To verify agency and plan performance (such             certain circumstances, we may deny your request.
   as audits);                                             If the GIC did not create the information you seek,
                                                           we will refer you to the source (e.g., your health
•	 To communicate with you about your GIC-
                                                           plan administrator). The GIC may charge you to
   sponsored benefits (such as your annual
                                                           cover certain costs, such as copying and postage.
   benefits statement);
                                                        •	 Ask the GIC to amend your PHI if you believe that
•	 For judicial and administrative proceedings
                                                           it is wrong or incomplete and the GIC agrees. You
   (such as in response to a court order);
                                                           must ask for this in writing, along with a reason
•	 For research studies that meet all privacy              for your request. If the GIC denies your request to
   requirements; and                                       amend your PHI, you may file a written statement
                                                           of disagreement to be included with your
•	 To tell you about new or changed benefits and
                                                           information for any future disclosures.
   services or health care choices.
                                                        •	 Get a listing of those with whom the GIC shares
Required Disclosures: The GIC must use and share
                                                           your PHI. You must ask for this in writing. The
your PHI when requested by you or someone who
                                                           list will not include health information that was:
has the legal right to act for you (your Personal
                                                           (1) collected prior to April 14, 2003; (2) given to
Representative), when requested by the United
                                                           you or your personal representative; (3) disclosed
States Department of Health and Human Services
                                                           with your specific permission; (4) disclosed to
to make sure your privacy is being protected, and
                                                           pay for your health care treatment, payment or
when otherwise required by law.
                                                           operations; or (5) part of a limited data set
Organizations that Assist Us: In connection with           for research.
payment and health care operations, we may share
                                                        •	 Ask the GIC to restrict certain uses and
your PHI with our third party “Business Associates”
                                                           disclosures of your PHI to carry out payment and
that perform activities on our behalf; for example,
                                                           health care operations; and disclosures to family
our Indemnity Plan administrator. When these
                                                           members or friends. You must ask for this in
services are contracted, we may disclose your health
                                                           writing. Please note that the GIC will consider the
information to our business associates so that they
                                                           request, but we are not required to agree to it and
can perform the job we have asked of them. These
                                                           in certain cases, federal law does not permit a
business associates will be contractually bound to
                                                           restriction.
safeguard the privacy of your PHI.
                                                        •	 Ask the GIC to communicate with you using
Except as described above, the GIC will not use or
                                                           reasonable alternative means or at an alternative
disclose your PHI without your written
                                                           address, if contacting you at the address we have
authorization. You may give us written authorization
                                                           on file for you could endanger you. You must tell
to use or disclose your PHI to anyone for any
                                                           us in writing that you are in danger, and where to
purpose. You may revoke your authorization so long
                                                           send communications.
as you do so in writing; however, the GIC will not be
able to get back your health information we have        •	 Receive a separate paper copy of this notice upon
already used or shared based on your permission.           request. An electronic version of this notice is on
                                                           the GIC website at www.mass.gov/gic.




                                                                                                            101
Appendix A


If you believe that your privacy rights may have been     There are two important things you need to know
violated, you have the right to file a complaint with     about your current coverage and Medicare’s
the GIC or the federal government. GIC complaints         prescription drug coverage:
should be directed to: GIC Privacy Officer, P.O. Box
                                                          (a) Medicare prescription drug coverage became
8747, Boston, MA 02114. Filing a complaint or
                                                              available in 2006 to everyone with Medicare.
exercising your rights will not affect your GIC
                                                              You can get this coverage if you join a Medicare
benefits. To file a complaint with the federal
                                                              Prescription Drug Plan or join a Medicare
government, you may contact the United States
                                                              Advantage Plan (like an HMO or PPO) that offers
Secretary of Health and Human Services. To
                                                              prescription drug coverage. All Medicare drug
exercise any of the individual rights described in this
                                                              plans provide at least a standard level of coverage
notice, or if you need help understanding this
                                                              set by Medicare. Some plans may also offer more
notice, please call (617) 727-2310, ext. 1 or TTY for
                                                              coverage for a higher monthly premium.
the deaf and hard of hearing at (617) 227-8583.
                                                          (b) The GIC has determined that the prescription
Important Notice from the Group                               drug coverage offered by your plan is, on average
                                                              for all participants, expected to pay out as much
Insurance Commission (GIC) about
                                                              as standard Medicare prescription drug coverage
Your Prescription Drug Coverage                               pays and is therefore considered Creditable
and Medicare                                                  Coverage. Because your existing coverage is
                                                              Creditable Coverage, you can keep this coverage
Please read this notice carefully and keep it where
                                                              and not pay a higher premium (a penalty) if you
you can find it. This notice has information about
                                                              later decide to join a Medicare drug plan.
your current prescription drug coverage with the
Plan and about your options under Medicare’s              When Can You Join a Medicare Drug Plan?
prescription drug coverage. This information can          You can join a Medicare drug plan when you first
help you decide whether or not you want to join a         become eligible for Medicare and each year from
Medicare drug plan. If you are considering joining,       October 15th to December 7th.
you should compare your current coverage,
                                                          However, if you lose your current creditable
including which drugs are covered at what cost, with
                                                          prescription drug coverage, through no fault of your
the coverage and costs of the plans offering
                                                          own, you will also be eligible for a two (2) month
Medicare prescription drug coverage in your area.
                                                          Special Enrollment Period (SEP) to join a Medicare
Information about where you can get help to make
                                                          drug plan.
decisions about your prescription drug coverage is at
the end of this notice.                                   What Happens to Your Current Coverage if You
                                                          Decide to Join a Medicare Drug Plan?
 FOR MOST PEOPLE, THE DRUG                                •	 You can continue to receive prescription drug
 COVERAGE THAT YOU CURRENTLY HAVE                            coverage through your GIC health plan rather
 THROUGH YOUR GIC HEALTH PLAN IS
                                                             than joining a Medicare drug plan. Most GIC
 A BETTER VALUE THAN THE MEDICARE
                                                             members do not need to do anything and should
 DRUG PLANS, SO YOU DON’T NEED TO
 PAY FOR ADDITIONAL DRUG COVERAGE.                           not enroll in a Medicare drug plan.
                                                          •	 Your GIC drug coverage is part of your GIC health
                                                             insurance which pays for your health expenses as
                                                             well as your prescription drugs.




102
Appendix A


•	 If you elect Medicare drug coverage, you will          For More Information about This Notice or
   have to pay for the entire Medicare drug               Your Current Prescription Drug Coverage …
   coverage premium.                                      Contact the GIC at (617) 727-2310, ext.1.
•	 If you should enroll in a Medicare drug plan while     NOTE: You’ll get this notice each year. You will also
   you are also enrolled in Fallon Senior Plan or Tufts   get it before the next period you can join a Medicare
   Health Plan Medicare Preferred, you will lose          drug plan, and if this coverage through the Group
   your GIC-sponsored health plan coverage under          Insurance Commission changes. You may request
   current Medicare rules.                                a copy of this notice at any time.
•	 If you have limited income and assets, the Social      For More Information about Your Options
   Security Administration offers help paying for         under Medicare Prescription Drug Coverage ...
   Medicare prescription drug coverage. Help is           More detailed information about Medicare plans
   available online at www.socialsecurity.gov, or by      that offer prescription drug coverage is in the
   phone at (800) 772-1213, or TTY: (800) 325-0778.       “Medicare & You” handbook. You’ll get a copy of the
•	 If you do decide to join a Medicare drug plan and      handbook in the mail every year from Medicare. You
   drop your current GIC health coverage, be aware        may also be contacted directly by Medicare drug
   that you and your dependents may not be able to        plans.
   get this coverage back.                                For more information about Medicare prescription
When Will You Pay a Higher Premium                        drug coverage:
(Penalty) to Join a Medicare Drug Plan?                   •	 Visit www.medicare.gov.
You should also know that if you drop or lose your
current coverage with a GIC plan and don’t join           •	 Call your State Health Insurance Assistance
a Medicare drug plan within 63 continuous days               Program (see the inside back cover of your copy
after your current coverage ends, you may pay                of the “Medicare & You” handbook for their
a higher premium (a penalty) to join a Medicare              telephone number) for personalized help.
drug plan later.                                          •	 Call 1-800-MEDICARE (1-800-633-4227);
If you go 63 continuous days or longer without               TTY users should call 1-877-486-2048.
creditable prescription drug coverage, your monthly       If you have limited income and resources, extra help
premium may go up by at least 1% of the Medicare          paying for Medicare prescription drug coverage is
base beneficiary premium per month for every              available. For information about this extra help, visit
month that you did not have that coverage. For            Social Security on the web at www.socialsecurity.gov,
example, if you go nineteen months without                or call them at 1-800-772-1213 (TTY 1-800-325-0778).
creditable coverage, your premium may consistently
be at least 19% higher than the Medicare base              Remember: Keep this Creditable Coverage
beneficiary premium. You may have to pay this              notice. If you decide to join one of the
higher premium (a penalty) as long as you have             Medicare drug plans, you may be required
Medicare prescription drug coverage. In addition,          to provide a copy of this notice when you
you may have to wait until the following November          join to show whether or not you have
to join.                                                   maintained creditable coverage and,
                                                           therefore, whether or not you are required
                                                           to pay a higher premium (a penalty).




                                                                                                             103
Appendix A


Important Information from the                              Prohibition against discrimination based on a
Group Insurance Commission about                            health factor
                                                            Under HIPAA, a group health plan may not keep
Your HIPAA Portability Rights                               you (or your dependents) out of the plan based on
                                                            anything related to your health. Also, a group health
Pre-existing condition exclusions                           plan may not charge you (or your dependents) more
Some group health plans restrict coverage for
                                                            for coverage, based on health, than the amount
medical conditions present before an individual’s
                                                            charged a similarly situated individual.
enrollment. These restrictions are known as “pre-
existing condition exclusions.” A pre-existing              Right to individual health coverage
condition exclusion can apply only to conditions for        Under HIPAA, if you are an “eligible individual,”
which medical advice, diagnosis, care, or treatment         you have a right to buy certain individual health
was recommended or received within a specified              policies (or in some states, to buy coverage through
period of time before your “enrollment date.” Your          a high-risk pool) without a pre-existing condition
enrollment date is your first day of coverage under         exclusion. To be an eligible individual, you must
the plan, or, if there is a waiting period, the first day   meet the following requirements:
of your waiting period. In addition, a pre-existing
                                                            •	 You have had coverage for at least 18 months
condition exclusion cannot last for more than
                                                               without a break in coverage of 63 days or more;
12 months after your enrollment date (in some
cases, 18 months if you are a late enrollee). Finally,      •	 Your most recent coverage was under a group
a pre-existing condition exclusion cannot apply to             health plan;
pregnancy or genetic information and cannot
                                                            •	 Your group coverage was not terminated because
apply to a child who is enrolled in health coverage
                                                               of fraud or nonpayment of premiums;
within 30 days after birth, adoption, or placement
for adoption.                                               •	 You are not eligible for COBRA continuation
                                                               coverage or you have exhausted your COBRA
If a plan imposes a pre-existing condition exclusion,
                                                               benefits (or continuation coverage under a similar
the length of the exclusion must be reduced by the
                                                               state provision); and
amount of your prior creditable coverage. Most
health coverage is creditable coverage, including           •	 You are not eligible for another group health plan,
group health plan coverage, COBRA continuation                 Medicare, or Medicaid, and do not have any other
coverage, coverage under an individual health                  health insurance coverage.
policy, Medicare, Medicaid, State Children’s Health
                                                            The right to buy individual coverage is the same
Insurance Program (SCHIP), and coverage through
                                                            whether you are laid off, fired, or quit your job.
high-risk pools and the Peace Corps. If you do not
receive a certificate for past coverage, talk to your       Therefore, if you are interested in obtaining
new plan administrator.                                     individual coverage and you meet the other criteria
                                                            to be an eligible individual, you should apply for this
You can add up any creditable coverage you have.
                                                            coverage as soon as possible to avoid losing your
However, if at any time you went for 63 days or
                                                            eligible individual status due to a 63-day break.
more without any coverage (called a break in
coverage) a plan may not have to count the
coverage you had before the break.




104
Appendix A


The Uniformed Services Employment                        For assistance in filing a complaint, or for any
                                                         other information on USERRA, contact VETS
and Reemployment Rights Act                              at 1-866-4-USA-DOL or visit its website at
(USERRA)                                                 http://www.dol.gov/vets. An interactive
The Uniformed Services Employment and                    online USERRA Advisor can be viewed at
Reemployment Rights Act (USERRA) protects the            http://www.dol.gov/elaws/userra.htm. If you file
rights of individuals who voluntarily or involuntarily   a complaint with VETS and VETS is unable to
leave employment positions to undertake military         resolve it, you may request that your case be referred
service or certain types of service in the National      to the Department of Justice or the Office of Special
Disaster Medical System. USERRA also prohibits           Counsel, as applicable, for representation. You
employers from discriminating against past and           may also bypass the VETS process and bring
present members of the uniformed services, and           a civil action against an employer for violations
applicants to the uniformed services. The GIC has        of USERRA. The rights listed here may vary
more generous guidelines for benefit coverage            depending on the circumstances.
that apply to persons subject to USERRA, as set          For more information, please contact the Group
forth below:                                             Insurance Commission at (617) 727-2310, ext. 1.
•	 If you leave your job to perform military service,
   you have the right to elect to continue your
   existing employer-based health plan coverage for
   you and your dependents while in the military.
•	 Even if you don’t elect to continue coverage during
   your military service, you have the right to be
   reinstated to GIC health coverage when you are
   reemployed, generally without any waiting periods
   or exclusions except for service-connected
   illnesses or injuries.
•	 Service members who elect to continue their GIC
   health coverage are required to pay the employee’s
   share for such coverage.
•	 USERRA coverage runs concurrently with COBRA
   and other state continuation coverage.
•	 The U.S. Department of Labor, Veterans
   Employment and Training Service (VETS) is
   authorized to investigate and resolve complaints
   of USERRA violations.




                                                                                                           105
Appendix A


Notice about the Federal Early Retiree Reinsurance Program
The notice below is a requirement of the federal Patient Protection and Affordable Care Act’s Early Retiree
Reinsurance Program, for which the Group Insurance Commission (GIC) has applied for reinsurance funds.
Although the GIC has received reinsurance funds, it is too early to say exactly how the GIC will allocate
such funds. The GIC’s expectation is that part of such funding would be used to enhance existing programs,
and part could be used to lower members’ costs, and to subsidize, in part, member claims costs. You will be
informed as to any such programs and benefit enhancements as soon as they are determined.

 You are a plan participant, or are being offered the opportunity to enroll as a plan participant, in an
 employment-based health plan that is certified for participation in the new federal health reform’s Early
 Retiree Reinsurance Program. The Early Retiree Reinsurance Program is a federal program that was
 established under the Patient Protection and Affordable Care Act. Under the Early Retiree Reinsurance
 Program, the federal government reimburses a plan sponsor of an employment-based health plan
 for some of the costs of health care benefits paid on behalf of, or by, early retirees and certain family
 members of early retirees participating in the employment-based plan. By law, the program expires
 on January 1, 2014.
 Under the Early Retiree Reinsurance Program, your plan sponsor may choose to use any reimbursements
 it received from this program to reduce or offset increases in plan participants’ premium contributions,
 copayments, deductibles, coinsurance or other out-of-pocket costs. If the plan sponsor chooses to use
 the Early Retiree Reinsurance Program reimbursements in this way, you, as a plan participant, may
 experience changes that may be advantageous to you, in your health plan coverage terms and conditions,
 for so long as the reimbursements under this program are available and this plan sponsor chooses to
 use the reimbursements for this purpose. A plan sponsor may also use the Early Retiree Reinsurance
 Program reimbursements to reduce or offset increases in its own costs for maintaining your health
 benefits coverage, which may increase the likelihood that it will continue to offer health benefits coverage
 to its retirees and employees and their families.
 If you have received this notice by email, you are responsible for providing a copy of this notice to your
 family members who are participants in this plan.




106
 Appendix B: 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 (18) 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 1-877-MA-ENROLL or visit the Connector website (www.mahealthconnector.org).
This health plan meets the Minimum Creditable Coverage standards that became effective July 1, 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, 2011. 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 (617) 521-7794
or visiting its website at www.mass.gov/doi.




                                                                                                             107
 Appendix C: Community Choice
 Hospital Listing
Athol, MA                      Brockton, MA                  Fitchburg, MA
Athol Memorial Hospital        Signature Healthcare          HealthAlliance Hospital –
2033 Main Street               Brockton Hospital             Burbank Campus
Athol, MA 01331                680 Center Street             275 Nichols Road
(978) 249-3511                 Brockton, MA 02302            Fitchburg, MA 01420
                               (508) 941-7000                (978) 343-5000
Boston, MA
Beth Israel Deaconess          Steward Good Samaritan        Framingham, MA
Medical Center                 Medical Center                MetroWest Medical Center –
330 Brookline Avenue           235 North Pearl Street        Framingham Union Hospital
Boston, MA 02215               Brockton, MA 02301            115 Lincoln Street
(617) 667-7000                 (508) 427-3000                Framingham, MA 01702
                                                             (508) 383-1000
Children’s Hospital Boston     Cambridge, MA
300 Longwood Avenue            Cambridge Health Alliance –   Gardner, MA
Boston, MA 02115               Cambridge Hospital            Heywood Hospital
(617) 355-6000                 1493 Cambridge Street         242 Green Street
                               Cambridge, MA 02139           Gardner, MA 01440
Dana-Farber Cancer Institute
                               (617) 665-1000                (978) 632-3420
44 Binney Street
Boston, MA 02115               Clinton, MA                   Greenfield, MA
(617) 632-3000                 Clinton Hospital              Baystate Franklin Medical Center
                               201 Highland Street           164 High Street
Massachusetts Eye and
                               Clinton, MA 01510             Greenfield, MA 01301
Ear Infirmary
                               (978) 368-3000                (413) 773-0211
243 Charles Street
Boston, MA 02114               Everett, MA                   Haverhill, MA
(617) 523-7900                 Cambridge Health Alliance –   Merrimack Valley Hospital
New England Baptist Hospital   Whidden Memorial Hospital     140 Lincoln Avenue
125 Parker Hill Avenue         103 Garland Street            Haverhill, MA 01830
Boston, MA 02120               Everett, MA 02149             (978) 374-2000
(617) 754-5800                 (617) 389-6270
                                                             Holyoke, MA
Steward Carney Hospital        Fall River, MA                Holyoke Medical Center
2100 Dorchester Avenue         Southcoast Health System –    575 Beech Street
Dorchester, MA 02124           Charlton Memorial Hospital    Holyoke, MA 01040
(617) 296-4000                 363 Highland Avenue           (413) 534-2500
                               Fall River, MA 02720
                               (508) 679-3131




108
Appendix C


Hyannis, MA                    Milford, MA                       Northampton, MA
Cape Cod Hospital              Milford Regional Medical Center   Cooley Dickinson Hospital
27 Park Street                 14 Prospect Street                30 Locust Street
Hyannis, MA 02601              Milford, MA 01757                 Northampton, MA 01061
(508) 771-1800                 (508) 473-1190                    (413) 582-2000
Leominster, MA                 Milton, MA                        Norwood, MA
HealthAlliance Hospital –      Milton Hospital                   Steward Norwood Hospital
Leominster Campus              199 Reedsdale Road                800 Washington Street
60 Hospital Road               Milton, MA 02186                  Norwood, MA 02062
Leominster, MA 01453           (617) 696-4600                    (781) 769-4000
(978) 466-2000
                               Natick, MA                        Palmer, MA
Lowell, MA                     MetroWest Medical Center –        Wing Memorial Hospital
Saints Medical Center          Leonard Morse Hospital            & Medical Centers
One Hospital Drive             67 Union Street                   40 Wright Street
Lowell, MA 01852               Natick, MA 01760                  Palmer, MA 01069
(978) 458-1411                 (508) 650-7000                    (413) 284-5400
Lynn, MA                       Needham, MA                       Pittsfield, MA
North Shore Medical Center –   Beth Israel Deaconess Hospital    Berkshire Medical Center
Union Hospital                 148 Chestnut Street               725 North Street
500 Lynnfield Street           Needham, MA 02192                 Pittsfield, MA 01201
Lynn, MA 01904                 (781) 453-3000                    (413) 447-2000
(781) 581-9200
                               New Bedford, MA                   Plymouth, MA
Marlborough, MA                Southcoast Health System –        Jordan Hospital
Marlborough Hospital           St. Luke’s Hospital               275 Sandwich Street
157 Union Street               101 Page Street                   Plymouth, MA 02360
Marlborough, MA 01752          New Bedford, MA 02740             (508) 746-2000
(508) 481-5000                 (508) 997-1515
                                                                 Quincy, MA
Methuen, MA                    Newburyport, MA                   Quincy Medical Center
Steward Holy Family Hospital   Anna Jaques Hospital              114 Whitwell Street
70 East Street                 25 Highland Avenue                Quincy, MA 02169
Methuen, MA 01844              Newburyport, MA 01950             (617) 773-6100
(978) 687-0151                 (978) 463-1000




                                                                                             109
Appendix C


Salem, MA                         Taunton, MA                   Westfield, MA
North Shore Children’s Hospital   Morton Hospital and           Noble Hospital
57 Highland Avenue                Medical Center                115 West Silver Street
Salem, MA 01970                   88 Washington Street          Westfield, MA 01085
(978) 745-2100                    Taunton, MA 02780             (413) 568-2811
                                  (508) 828-7000
North Shore Medical Center –                                    Winchester, MA
Salem Hospital                    Ware, MA                      Winchester Hospital
81 Highland Avenue                Baystate Mary Lane Hospital   41 Highland Avenue
Salem, MA 01970                   85 South Street               Winchester, MA 01890
(978) 741-1200                    Ware, MA 01082                (781) 729-9000
                                  (413) 967-6211
Springfield, MA                                                 Worcester, MA
Baystate Medical Center           Wareham, MA                   Saint Vincent Hospital
759 Chestnut Street               Southcoast Health System –    123 Summer Street
Springfield, MA 01199             Tobey Hospital                Worcester, MA 01608
(413) 794-0000                    43 High Street                (508) 363-5000
                                  Wareham, MA 02571
Mercy Medical Center
                                  (508) 295-0880
271 Carew Street
Springfield, MA 01104
(413) 748-9000




110
  Appendix D: Designated Hospitals for
  Select Complex Inpatient Procedures
  and Neonatal ICUs
There is a $250 copay per calendar year quarter for inpatient care at all Community Choice hospitals. Also, as
a Community Choice Plan member you can use the following additional non-Community Choice hospitals
at the $250 inpatient copay level for certain complex procedures and for neonatal ICU care, as indicated in
the chart below.



                             Brigham              Lahey Clinic         Massachusetts              Mount                Tufts
                           and Women’s              Medical              General                 Auburn               Medical
                             Hospital               Center               Hospital                Hospital             Center
 Abdominal
 Aortic Aneurysm
 Repair
                                   •                     •                      •                     •                    •
 Cardiac Valve
 Procedures                        •                                            •
 Esophagectomy                     •                     •                      •
 Neonatal ICUs                     •                                            •                                          •
 Pancreatic
 Resection                         •                     •                      •
The listed procedures have been designated by the Leapfrog Group for Patient Safety1 as complex procedures
that studies indicate are most safely performed at hospitals that meet the following dual-criteria: 1) the
facilities have significant experience in performing the procedure and 2) they demonstrate specific clinical
practices established by the Leapfrog Group.




1 The Leapfrog Group is an initiative driven by organizations that buy health care who are working to initiate breakthrough
improvements in the safety, quality and affordability of health care for Americans. Leapfrog is a member-supported program aimed at
mobilizing employer purchasing power to alert America’s health industry that big leaps in health care safety, quality and customer
value will be recognized and rewarded. To learn about the Leapfrog Group’s patient safety initiatives, visit www.unicarestateplan.com >
“Members” > “Health Care Quality Initiatives.”



                                                                                                                                  111
112
     Appendix E: Claim Form
                                                                      !"#$%&'()#*'(+(,'%)-,(#".!&%"$'($/01%"2(
                                                                                %"3/4'&(.'&4#$'($'"-'&(
                                                                                   $)%#0.(3'1%&-0'"-(
                                                                                      15/5(6/7(89:;(
                                                                                %"3/4'&<(0%(9:=:9>98:;(
                                                                        -?@A(B=99C(DDE>8F99(((((*GHA(B8I=C(DID>J:;E(
                                                                                              (
($%.'("/5(:F::8E(K!
                               .'$-#/"(:A((((2LM(NMOP(QLNR@?P?(PSTO(O?QPTLU(VS?U(WT@TUX(G(Q@GTN5(
    "#$%&'(#!)#*#+%&%'(,!      C3/21,##K0!:!L#.%(##K0!A'3#!M/2#'0#!/(%*.N!                                                          C3/21,##K0!:!L#.%(##K0!71&@!7#&@!A1@!:!QR!A1@!
    -+.#(!"#$%&'(#!/',0!       ! O'0.!! ! P%(0.!! ! "Q!                                                                             !
    %.0!/1(.%1*!1+!'!&2'%3!                                                                                                         !
    +1(!3#$%&'2!&4'(5#06!                                                                                                           C3/21,##!:!L#.%(##!"#$%&'(#!A1@!!
    /2#'0#!&13/2#.#!                                                                                                                !
    7#&.%1*!86!'..'&4!.4#!                                                                                                          !
    #9/2'*'.%1*!1+!            C3/21,##K0!:!L#.%(##K0!7.(##.!-$$(#00!                                                               ?%.,6!7.'.#!'*$!S%/!?1$#!
    "#$%&'(#!/',3#*.!                                                                                                               !
    '*$:1(!'*,!;%22!.4'.!
                                                                                                                                    !
    %*$%&'.#0!.4#!.1.'2!
    /(1<%$#(!&4'(5#6!.4#!                                                                                                           E41*#!A1@!!!M!!!!!!!!!!N!
    "#$%&'(#!'221=#$!
    &4'(5#!'0!=#22!'0!.4#!     .'$-#/"(EA((((#W(YLM(GZ?(G(0?[TQGZ?(6?U?WTQTGZY<(R@?GO?(OPLR(S?Z?@!
    "#$%&'(#!/',3#*.6!         T1H(!R'.#!1+!)%(.4!                                                              "'(%.'2!7.'.H0!M&4#&U!1*#N!
                                                                                     "'2#! !
    '*$!0#*$!.1!>*%?'(#@!      !                                                                                !!!!7%*52#! ! !!!!!!!!R%<1(&#$!
    !                                                                                P#3'2# !
                                                                                                                !!!!!"'((%#$! !!!!!!!!O#5'22,!7#/'('.#$
    A1*B"#$%&'(#!              A'3#!1+!7/1H0#!                                       7/1H0#K0!                  A'3#!'*$!'$$(#00!1+!7/1H0#K0!C3/21,#(!
    C*(122##0D!                !                                                     R'.#!1+!)%(.4!
    E2#'0#!&13/2#.#!           !                                                     !
    7#&.%1*0!86!F6!'*$!G!%*!
                               !
    1($#(!.1!(#&#%<#!
                               Q0!&2'%3!+1(!,1H(!!!         A'3#!1+!R#/#*$#*.6!%+! L#2'.%1*04%/!.1!,1H!           R#/#*$#*.K0!!            Q0!,1H(!R#/#*$#*.!3'((%#$V!
    /(13/.!
                               7/1H0#:R#/#*$#*.V!           1.4#(!.4'*!7/1H0#!                                    R'.#!1+!)%(.4!!               !!!A1! !!!T#0!
    (#%3;H(0#3#*.@!            !                                                   !!!?4%2$! !!!!!!7.#/&4%2$!
    7#&.%1*!I!&'*!;#!                                                                                                                      PH22BX%3#!7.H$#*.V! !!!A1! !!!T#0!
                               !!!!A1!!!!!T#0                                                !
                                                                                   !!!W.4#(! !!!!!7/1H0#!
    &13/2#.#$!;,!,1H(!                                                                                                                     C3/21,#$!PH22BX%3#V !!!A1! !!!T#0
    /4,0%&%'*!1(!'*!
    %.#3%J#$!;%22!&'*!;#!      R'.#!1+!+%(0.!.(#'.3#*.!+1(!.4%0!%22*#00!1(!%*YH(,! A'3#!'*$!'$$(#00!1+!R1&.1(!M/2#'0#!/(%*.N!!
    0H;3%..#$!%*!/2'&#!1+!     !
    7#&.%1*!I@!                !
                               !
                               !
                               Q0!.4%0!&1*$%.%1*!$H#! Q0!.4%0!&1*$%.%1*!$H#!.1!'*!           R'.#!1+!       Z4#(#!$%$!%.!1&&H(V!
                               .1!'*!%*YH(,V!           1&&H/'.%1*'2!%*YH(,!1(!$%0#'0#V!     %*YH(,!
                               !!!!A1!!!!!T#0           !!!!A1!!!!!T#0!

                               R#0&(%;#!41=!'&&%$#*.!4'//#*#$!
                               !
                               !
                               -(#!,1H6!,1H(!7/1H0#!1(!,1H(!R#/#*$#*.!           Q+!T#06!A'3#!1+!"#3;#(!:!7H;0&(%;#(!     L#2'.%1*04%/!.1!          W.4#(!\(1H/:E12%&,:?1*.('&.!A1@!
                               &4%2$(#*!%*!'*,!1.4#(![#'2.4!)#*#+%.!E2'*!        M%+!$%++#(#*.!+(13!E'.%#*.N!             E'.%#*.!
                               Q*&2H$%*5!"#$%&'(#V!
                               !!!!!!!!!!!A1!!   !!!!T#0!

                               "#3;#(!:!7H;0&(%;#(!A1@!                          A'3#!'*$!'$$(#00!1+!1.4#(!E2'*!?2'%3!E',3#*.!W++%&#!
                                                                                 !
                                                                                 !
                                                                                 !
#U(QLUOT[?ZGPTLU(LW(\?U?WTP(RGYN?UP(H*$#(!.4%0!\(1H/!E12%&,6!=%.41H.!(#$H&.%1*!+1(!'*,!(%54.!1+!(#&1<#(,!H*$#(!.4#!Z1(U#(K0!?13/#*0'.%1*!-&.6!Q!'00%5*!.1!.4#!
>*%?'(#!O%+#!]![#'2.4!Q*0H('*&#!?13/'*,!3,!(%54.6!.%.2#6!'*$!%*.#(#0.!.1!'*,!(#&1<#(,!1+!Z1(U#(0K!?13/#*0'.%1*!;#*#+%.0!+1(!.4%0!$%0#'0#!1(!%*YH(,6!41=#<#(!!
(#&1<#(#$6!.1!.4#!#9.#*.!1+!;#*#+%.0!/'%$!H*$#(!.4%0!\(1H/!E12%&,@!
#(GMPSLZT]?!'*,!/4,0%&%'*!1(!1.4#(!3#$%&'2!/(1+#00%1*'26!410/%.'2!1(!1.4#(!3#$%&'2!&'(#!%*0.%.H.%1*6!%*0H(#(6!3#$%&'2!1(!410/%.'2!0#(<%&#!1(!/(#/'%$!4#'2.4!/2'*6!
#3/21,#(!1(!5(1H/!/12%&,412$#(6!&1*.('&.!412$#(!1(!;#*#+%.!/2'*!'$3%*%0.('.1(!.1!$%0&210#!.1!>*%?'(#!O%+#!]![#'2.4!Q*0H('*&#!?13/'*,!1(!'*,!/2'*!'$3%*%0.('.1(6!
&1*0H3#(!(#/1(.%*5!'5#*&,6!1(!'..1(*#,!'&.%*5!1*!>*%?'(#!O%+#!]![#'2.4!Q*0H('*&#!?13/'*,K0!;#4'2+6!'*,!3#$%&'2!%*+1(3'.%1*!'*$!'*,!#3/21,3#*.!(#2'.#$!
%*+1(3'.%1*!(#5'($%*5!.4#!/'.%#*.@!!X4%0!%*+1(3'.%1*!=%22!;#!H0#$!1*2,!.1!#<'2H'.#!'*$!'$3%*%0.#(!&2'%30!+1(!;#*#+%.0@!
X4%0!'H.41(%J'.%1*!%0!<'2%$!+1(!.4#!$H('.%1*!1+!.4#!&2'%3@!
Q!U*1=!Q!4'<#!'!(%54.!.1!(#&#%<#!'!&1/,!1+!.4%0!'H.41(%J'.%1*!'*$!.4'.!'!/41.15('/4%&!&1/,!%0!'0!<'2%$!'0!.4#!1(%5%*'2@!
-*,!/#(01*!=41!U*1=%*52,!+%2#0!'!0.'.#3#*.!1+!&2'%3!&1*.'%*%*5!+'20#6!%*&13/2#.#!1(!3%02#'$%*5!%*+1(3'.%1*!=%.4!%*.#*.!.1!%*YH(#6!$#+('H$6!1(!$#&#%<#!'*,!%*0H('*&#!
&13/'*,!%0!5H%2.,!1+!'!&(%3#@!
!
!
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^            !^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^!              ^^^^^^^^^^^^^^^^^^^^^^^^^!
C3/21,##K0:L#.%(##K0!7%5*'.H(#!                           E'.%#*.!7%5*'.H(#6!%+!/'.%#*.!%0!*1.!#3/21,##!             R'.#!
!                                                         ME'(#*.6!%+!/'.%#*.!%0!'!3%*1(N!
!
K( >*%?'(#!$1#0!*1.!%*0H(#!;#*#+%.0!H*$#(!&'0#!*H3;#(!8G88_F@!T1H(!#3/21,#(!%0!012#2,!(#0/1*0%;2#!+1(!$#.#(3%*'.%1*!1+!#*.%.2#3#*.!.16!'*$!/',3#*.!1+6!'*,!                          113
   '31H*.0!$H#!H*$#(!.4#!/2'*@!
  Appendix E: Claim Form


   .'$-#/"(F((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((1%-#'"-(#"*/&0%-#/"(
   E'.%#*.K0!A'3#!                                                                                                    E'.%#*.K0!7#9!               E'.%#*.K0!(#2'.%1*04%/!.1!C3/21,##!:!L#.%(##!
   ! O'0.!! ! P%(0.!! ! "Q!!                                                                                                                       !!!!!!!!7#2+!! ! !!!!!!!?4%2$!
                                                                                                                      !!!!"'2#    !!!!P#3'2#!
                                                                                                                                                   !!!!!!!!7/1H0#!!!!!!!!W.4#(!
   E'.%#*.K0!7.(##.!-$$(#00!                                                                                          E'.%#*.K0!R'.#!1+!)%(.4!     Z'0!&1*$%.%1*!(#2'.#$!.1D!
                                                                                                                      !                            E'.%#*.K0!#3/21,3#*. !!!!!T#0 !!!!A1!
                                                                                                                      !                            -*!'H.1!'&&%$#*.!       !!!!!T#0! !!!!A1!
   W.4#(![#'2.4!Q*0H('*&#!?1<#('5#!`!C*.#(!*'3#!1+!/12%&,412$#(!'*$!E2'*!*'3#!'*$!                                    Q*0H(#$K0!Q@R@!A1@!          Q*0H(#$K0!\(1H/!A1@!M1(!\(1H/!A'3#N!
   '$$(#00!'*$!E12%&,!1(!"#$%&'2!-00%0.'*&#!*H3;#(!M%*&2H$%*5!"#$%&'%$6!"#$%&'(#N!                                    M7@7@!A1@N!
   !
   !
   !
   E'.%#*.K0!1(!-H.41(%J#$!E#(01*K0!7%5*'.H(#!                                                                        Q*0H(#$K0!A'3#!
   Q!-H.41(%J#!.4#!L#2#'0#!1+!'*,!"#$%&'2!Q*+1(3'.%1*!A#&#00'(,!.1!E(1&#00!.4%0!?2'%3!
   !
   7(
   X4#!>*%?'(#!7.'.#!Q*$#3*%.,!E2'*!=%22!/',!;#*#+%.0!$%(#&.2,!.1!.4#!/(1<%$#(!H*2#00!'!                              Q*0H(#$K0!-$$(#00!
   (#&#%/.#$!;%22!%0!'..'&4#$@!
   !
   !



   .'$-#/"(D((((((((((((((((((((((((((((((((((((((((((((((((((((((((1,2.#$#%"(/&(.!11)#'&(#"*/&0%-#/"(
   R'.#!1+!%22*#00!M+%(0.!0,3/.13N!1(!%*YH(,!                          R'.#!+%(0.!&1*0H2.#$!,1H!+1(! E'.%#*.!#<#(!4'$!0'3#!1(!      R'.#0!1+!X1.'2!R%0';%2%.,!        R'.#0!1+!E'(.%'2!R%0';%2%.,!
   M'&&%$#*.N!1(!/(#5*'*&,!MO"EN!                                      .4%0!&1*$%.%1*!               0%3%2'(!0,3/.130V!             !!!!!P(13! !!!!!!!!!!!X4(1H54!    !!!!P(13! !!!!!X4(1H54!
                                                                       !                                    !!!!T#0 !!!!A1!
                                                                       !
   A'3#!1+!L#+#((%*5!E4,0%&%'*!                                                                      P1(!0#(<%&#0!(#2'.#$!.1!410/%.'2%J'.%1*6!5%<#!410/%.'2%J'.%1*!$'.#0!
   !
                                                                             %[NTPP?[(( ( 3TOQSGZX?[(
   !
   !
   A'3#!'*$!'$$(#00!1+!+'&%2%.,!=4#(#!0#(<%&#0!(#*$#(#$!M%+!1.4#(!.4'*!413#!1(! Z'0!2';1('.1(,!=1(U!/#(+1(3#$!1H.0%$#!,1H(!        R'.#!/'.%#*.!';2#!.1!
   1++%&#N!                                                                     1++%&#V!                                           (#.H(*!.1!=1(U!
                                                                                                                                   !
                                                                                             !!!!T#0 !!!!A1!?4'(5#0(
                                                                                                                                   !
   R%'5*10%0!1(!*'.H(#!1+!%22*#00!1(!%*YH(,6!&')%-'(#$38(-/(1&/$'3!&'(#"($/)!0"(3(62(&'*'&'"$'(-/("!06'&.(:<(E<(F<('-$5(/&(37($/3'((
   8@!
   F@!
   G@!
   I@(
                                     PH22,!$#0&(%;#!/(1&#$H(#06!3#$%&'2!0#(<%&#!1(!0H//2%#0!+H(*%04#$!             R!
       R'.#!1+!       E2'&#!1+!      +1(!#'&4!$'.#!5%<#*!                                                      R%'5*10%0!
       7#(<%&#!      7#(<%&#h!       !!!E(1&#$H(#!?1$#!!                                                         ?1$#!    ?4'(5#0!           !
                                     !     ?EXI!!!!!!!!!!!!!!!!MC9/2'%*!H*H0H'2!0#(<%&#0!1(!&%(&H30.'*&#0N!      Q?R_!




   7%5*'.H(#!1+!E4,0%&%'*!1(!7H//2%#(!                                                                       iH#0.%1*0!a6!d!]!_!3H0.!;#!         X1.'2!?4'(5#!   -31H*.!E'%$!       )'2'*&#!RH#!
   !                                                                                                         '*0=#(#$!H*$#(!'H.41(%.,!1+!
   !                                                                                                         2'=!
   !
   !                                                                                                         a@!!T1H(!XQA!                       d@!! E4,0%&%'*K0!1(!7H//2%#(K0!A'3#6!!
   7%5*#$!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!R'.#!                                                       -$$(#006!S%/!?1$#!]!X#2#/41*#!A1@!
                                                                                                                                                 !
   T1H(!E'.%#*.K0!-&&1H*.!A1@!!                                                                              _@!!T1H(!C3/21,#(!Q@R@!A1@!         !
                                                                                                                                                 !
                                                                                                                                                 Q@R@!A1@!!



† PLACE OF SERVICE CODES

!
8`!!M[N!! `QAE-XQCAX![W7EQX-O! !                      I`!!M[N!`E-XQCAXK7![W"C! ! ! ! a`!!MA[N!!!`A>L7QA\![W"C! ! ! ! ! ! ! b`!MWON!! `WX[CL!OW?-XQWA7!
F`!!Mb[N! !`W>XE-XQCAX![W7EQX-O!                      c`!!R-T!?-LC!P-?QOQXT!ME7TN!! ! d`!!M7APN!`7eQOOCR!A>L7QA\!P-?QOQXT!! ! -`!MQON!! `QARCECARCAX!O-)WL-XWLT!
G`!!MbN!! !`RW?XWLK7!WPPQ?C!! ! !                     f`!!AQ\[X!?-LC!P-?QOQXT!ME7TN!! _`!!-")>O-A?C! ! ! ! ! ! ! ! ! ! ! ! )`!! ! ! `!WX[CL!"CRQ?-O:7>L\Q?-O!P-?QOQXT!
!
                ! ! ! ! ! ! ! ! !                      ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! -EELWgCR!)T!-"-!?W>A?QO!WA!"CRQ?-O!7CLgQ?C!fBaI!




  114
  Appendix F: Bill Checker Program
The Plan’s Bill Checker Program gives you the opportunity to share in any savings resulting from errors you
detect on your medical bills. Please note that duplicate claims and services not covered under the Plan will
not be reviewed under the Bill Checker Program.
Please attach a photocopy of both the initial and revised bills and mail them to:
Andover Service Center
P.O. Box 9016
Andover, MA 01810-0916




Enrollee ID #




Patient Name




Hospital Name




Date of Service



Inpatient:        Yes      No



Outpatient:       Yes      No




                                                                                                         115
  Appendix G: Federal and State Mandates
•	 Medicaid and the Children’s Health Insurance          If you or your dependents are NOT currently
   Program (CHIP) Offer Free or Low-Cost Health          enrolled in Medicaid or CHIP, and you think you or
   Coverage to Children and Families                     any of your dependents might be eligible for either
                                                         of these programs, you can contact your state
•	 Coverage for Reconstructive Breast Surgery
                                                         Medicaid or CHIP office or dial 1-877-KIDS-NOW
•	 Minimum Maternity Confinement Benefits                or www.insurekidsnow.gov to find out how to apply.
                                                         If you qualify, you can ask the state if it has a
Medicaid and the Children’s Health                       program that might help you pay the premiums for
                                                         an employer-sponsored plan.
Insurance Program (CHIP) Offer
Free or Low-Cost Health Coverage                         Once it is determined that you or your dependents
                                                         are eligible for premium assistance under Medicaid
to Children and Families                                 or CHIP, your employer’s health plan is required
If you are eligible for health coverage from your        to permit you and your dependents to enroll in
employer, but are unable to afford the premiums,         the plan – as long as you and your dependents are
some states have premium assistance programs that        eligible, but not already enrolled in the employer’s
can help pay for coverage. These states use funds        plan. This is called a “special enrollment” opportunity,
from their Medicaid or CHIP programs to help             and you must request coverage within 60 days of
people who are eligible for employer-sponsored           being determined eligible for premium assistance.
health coverage, but need assistance in paying their
                                                         If you live in one of the following states, you may be
health premiums.
                                                         eligible for assistance paying your employer health
If you or your dependents are already enrolled in        plan premiums. The following list of states is
Medicaid or CHIP and you live in a state listed          current as of January 31, 2011. You should contact
below, you can contact your state Medicaid or CHIP       your state for further information on eligibility.
office to find out if premium assistance is available.

 ALABAMA – Medicaid                                      CALIFORNIA – Medicaid
 Website: http://www.medicaid.alabama.gov                Website: http://www.dhcs.ca.gov/services/Pages/
 Phone: 1-800-362-1504                                   TPLRD_CAU_cont.aspx
                                                         Phone: 1-866-298-8443
 ALASKA – Medicaid                                       COLORADO – Medicaid and CHIP
 Website: http://health.hss.state.ak.us/dpa/programs/    Medicaid Website: http://www.colorado.gov/
 medicaid/                                               Medicaid Phone (In state): 1-800-866-3513
 Phone (Outside of Anchorage): 1-888-318-8890            Medicaid Phone (Out of state): 1-800-221-3943
 Phone (Anchorage): 907-269-6529                         CHIP Website: http:// www.CHPplus.org
 ARIZONA – CHIP                                          CHIP Phone: 303-866-3243
 Website: http://www.azahcccs.gov/applicants/
 default.aspx
 Phone (Outside of Maricopa County):
 1-877-764-5437
 Phone (Maricopa County): 602-417-5437



116
Appendix G


ARKANSAS – CHIP                                   FLORIDA – Medicaid
Website: http://www.arkidsfirst.com/              Website:	http://www.fdhc.state.fl.us/Medicaid/
Phone: 1-888-474-8275                             index.shtml
                                                  Phone: 1-877-357-3268
GEORGIA – Medicaid                                MISSOURI – Medicaid
Website: http://dch.georgia.gov/                  Website: http://www.dss.mo.gov/mhd/participants/
  Click on Programs, then Medicaid                pages/hipp.htm
Phone: 1-800-869-1150                             Phone: 573-751-2005

IDAHO – Medicaid and CHIP                         MONTANA – Medicaid
Medicaid Website: www.accesstohealthinsurance.    Website: http://medicaidprovider.hhs.mt.gov/
idaho.gov                                         clientpages/clientindex.shtml
Medicaid Phone: 1-800-926-2588                    Phone: 1-800-694-3084
CHIP Website: www.medicaid.idaho.gov
CHIP Phone: 1-800-926-2588
INDIANA – Medicaid                                NEBRASKA – Medicaid
Website: http://www.in.gov/fssa                   Website: http://www.dhhs.ne.gov/med/medindex.
Phone: 1-800-889-9948                             htm
                                                  Phone: 1-877-255-3092
IOWA – Medicaid                                   NEVADA – Medicaid and CHIP
Website: www.dhs.state.ia.us/hipp/                Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562                             Medicaid Phone: 1-800-992-0900
KANSAS – Medicaid                                 CHIP Website: http://www.nevadacheckup.nv.org/
                                                  CHIP Phone: 1-877-543-7669
Website: https://www.khpa.ks.gov
Phone: 1-800-792-4884
KENTUCKY – Medicaid                               NEW HAMPSHIRE – Medicaid
Website: http://chfs.ky.gov/dms/default.htm       Website: www.dhhs.nh.gov/ombp/index.htm
Phone: 1-800-635-2570                             Phone: 603-271-4238
LOUISIANA – Medicaid                              NEW JERSEY – Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov      Medicaid Website: http://www.state.nj.us/
Phone: 1-888-342-6207                             humanservices/dmahs/clients/medicaid/
                                                  Medicaid Phone: 1-800-356-1561
MAINE – Medicaid
                                                  CHIP Website: http://www.njfamilycare.org/index.
Website: http://www.maine.gov/dhhs/OIAS/public-   html
assistance/index.html
                                                  CHIP Phone: 1-800-701-0710
Phone: 1-800-321-5557




                                                                                                   117
Appendix G


 MASSACHUSETTS – Medicaid and CHIP                 NEW MEXICO – Medicaid and CHIP
 Medicaid & CHIP Website: http://www.mass.gov/     Medicaid Website: http://www.hsd.state.nm.us/
 MassHealth                                        mad/index.html
 Medicaid & CHIP Phone: 1-800-462-1120             Medicaid Phone: 1-888-997-2583
                                                   CHIP Website:
 MINNESOTA – Medicaid                              http://www.hsd.state.nm.us/mad/index.html
                                                       Click on Insure New Mexico
 Website: http://www.dhs.state.mn.us/
                                                   CHIP Phone: 1-888-997-2583
   Click on Health Care, then Medical Assistance
 Phone (Outside of Twin City area): 800-657-3739
 Phone (Twin City area): 651-431-2670
 NEW YORK – Medicaid                               TEXAS – Medicaid
 Website: http://www.nyhealth.gov/health_care/     Website: https://www.gethipptexas.com/
 medicaid/                                         Phone: 1-800-440-0493
 Phone: 1-800-541-2831
 NORTH CAROLINA – Medicaid                         UTAH – Medicaid
 Website: http://www.nc.gov                        Website: http://health.utah.gov/upp
 Phone: 919-855-4100                               Phone: 1-866-435-7414
 NORTH DAKOTA – Medicaid                           VERMONT– Medicaid
 Website: http://www.nd.gov/dhs/services/          Website: http://www.greenmountaincare.org/
 medicalserv/medicaid/                             Phone: 1-800-250-8427
 Phone: 1-800-755-2604

 OKLAHOMA – Medicaid                               VIRGINIA – Medicaid and CHIP
 Website: http://www.insureoklahoma.org            Medicaid Website: http://www.dmas.virginia.gov/
 Phone: 1-888-365-3742                             rcp-HIPP.htm
                                                   Medicaid Phone: 1-800-432-5924
                                                   CHIP Website: http://www.famis.org/
                                                   CHIP Phone: 1-866-873-2647
 OREGON – Medicaid and CHIP                        WASHINGTON – Medicaid
 Medicaid & CHIP Website:                          Website: http://hrsa.dshs.wa.gov/premiumpymt/
 http://www.oregonhealthykids.gov                  Apply.shtm
 Medicaid & CHIP Phone: 1-877-314-5678             Phone: 1-800-562-3022 ext. 15473

 PENNSYLVANIA – Medicaid                           WEST VIRGINIA – Medicaid
 Website: http://www.dpw.state.pa.us/              Website: http://www.wvrecovery.com/hipp.htm
 partnersproviders/medicalassistance/              Phone: 304-342-1604
 doingbusiness/003670053.htm
 Phone: 1-800-644-7730




118
Appendix G


 RHODE ISLAND – Medicaid                               WISCONSIN – Medicaid
 Website: www.dhs.ri.gov                               Website: http://www.badgercareplus.org/
 Phone: 401-462-5300                                   pubs/p-10095.htm
                                                       Phone: 1-800-362-3002

 SOUTH CAROLINA – Medicaid                             WYOMING – Medicaid
 Website: http://www.scdhhs.gov                        Website: http://www.health.wyo.gov/healthcarefin/
 Phone: 1-888-549-0820                                 index.html
                                                       Phone: 307-777-7531

To see if any more states have added a premium assistance program since January 31, 2011, or for more
information on special enrollment rights, you can contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Ext. 61565




                                                                                                        119
Appendix G


Coverage for Reconstructive                            Any decision to shorten the minimum confinement
                                                       period will be made by the attending physician
Breast Surgery                                         in consultation with the mother. If a shortened
Coverage is provided for reconstructive breast         confinement is elected, coverage will include one
surgery as follows:                                    home visit for post-delivery care.
(a) All stages of breast reconstruction following      Home post-delivery care is defined as health
    a mastectomy                                       care provided to a woman at her residence by
                                                       a physician, registered nurse or certified nurse
(b) Reconstruction of the other breast to produce
                                                       midwife. The health care services provided
    a symmetrical appearance after mastectomy
                                                       must include, at a minimum:
(c) Prostheses and treatment of physical
                                                       1. Parent education
    complications of all stages of mastectomy,
    including lymphedemas                              2. Assistance and training in breast or bottle
                                                          feeding, and
Benefits for reconstructive breast surgery will be
payable on the same basis as any other illness or      3. Performance of necessary and appropriate
injury under the Plan, including the application of       clinical tests
appropriate deductibles and coinsurance amounts.
                                                       Any subsequent home visits must be clinically
Several states have enacted similar laws requiring     necessary and provided by a licensed health
coverage for treatment related to mastectomy.          care provider.
If the law of your state is applicable and is more
                                                       You must notify the Plan within 24 hours –
generous than the federal law, your benefits will
                                                       one (1) business day – of being admitted to the
be paid in accordance with your state’s law.
                                                       hospital. Please call a patient advocate at the
                                                       Andover Service Center if you have questions.
Minimum Maternity
Confinement Benefits
Coverage is provided for inpatient hospital services
for a mother and newborn child for a minimum of:
1. 48 hours following an uncomplicated vaginal
   delivery, and
2. 96 hours following an uncomplicated
   caesarean section




120
  Appendix H: Your Right to Appeal
This Appendix describes how UniCare handles                            •	 A description of any additional material or
member appeals in accordance with federal                                 information needed to reconsider your claim;
regulations.
                                                                       •	 An explanation of why the additional material or
For purposes of these Appeal provisions, “claim for                       information is needed;
benefits” means a request for benefits under the
                                                                       •	 A description of the plan’s review procedures and
plan. The term includes both pre-service and post-
                                                                          the time limits that apply to them;
service claims.
                                                                       •	 Information about any internal rule, guideline,
•	 A pre-service claim is a claim for benefits under
                                                                          protocol, or other similar criterion relied upon in
   the plan for which you have not received the
                                                                          making the claim determination, and about your
   benefit or for which you may need to obtain
                                                                          right to request a copy of it free of charge;
   approval in advance.
                                                                       •	 Information about your right to a discussion of
•	 A post-service claim is any other claim for
                                                                          the claims denial decision;
   benefits under the plan for which you have
   received the service.                                               •	 Information about the scientific or clinical
                                                                          judgment for any determination based on medical
If your claim is denied or if your coverage is
                                                                          necessity or experimental treatment, and about
rescinded:
                                                                          your right to request this explanation free of
•	 You will be provided with a written notice of                          charge, along with a discussion of the claims
   the denial or rescission1; and                                         denial decision; and
•	 You are entitled to a full and fair review of the                   •	 The availability of, and contact information for, any
   denial or rescission.                                                  applicable office of health insurance consumer
                                                                          assistance or ombudsman who may assist you.
The procedure UniCare follows satisfies the
requirements for a full and fair review under                          For claims involving urgent/concurrent care:
applicable federal regulations.
                                                                       •	 UniCare’s notice will also include a description of
                                                                          the applicable urgent/concurrent review process; and
Notice of Adverse
                                                                       •	 UniCare may notify you or your authorized
Benefit Determination
                                                                          representative within 24 hours orally and then
If your claim is denied, UniCare’s notice of the                          furnish a written notification.
adverse benefit determination (denial) will include
the following, when applicable:
•	 Information sufficient to identify the claim
   involved;
•	 The specific reason(s) for the denial;
•	 A reference to the plan provision(s) on which
   UniCare’s determination is based;


1 A rescission is a retroactive termination of coverage as a result of fraud or an intentional misrepresentation of material fact. A
cancellation or discontinuance of coverage is not a rescission if the cancellation has a prospective effect or if the cancellation is due
to a failure to timely pay required premiums or contributions toward the cost of coverage.



                                                                                                                                     121
Appendix H


Appeals                                                 All other requests for appeals should be submitted
                                                        in writing by the member or the member’s
You have the right to appeal an adverse benefit         authorized representative, except where the
determination. You or your authorized                   acceptance of oral appeals is otherwise required
representative must file your appeal within             by the nature of the appeal (e.g., urgent care). You
180 calendar days after you are notified of the         or your authorized representative must submit
denial or rescission. You will have the opportunity     a request for review to:
to submit written comments, documents, records,
and other information supporting your claim.            UniCare State Indemnity Plan
UniCare’s review of your claim will take into           P.O. Box 2011
account all information you submit, regardless          Andover, MA 01810-0916
of whether it was submitted or considered in the        Upon request, UniCare will provide reasonable
initial benefit determination.                          access to, and copies of, all documents, records, and
UniCare shall offer a single internal level of appeal   other information relevant to your claim. “Relevant”
and an External Review process. The time frame          means that the document, record, or other
allowed for UniCare to complete its review is           information:
dependent upon the type of review involved (e.g.,       •	 Was relied on in making the benefit
pre-service, concurrent, post-service, urgent, etc.).      determination; or
For pre-service claims involving urgent/concurrent      •	 Was submitted, considered, or produced in the
care, you may obtain an expedited appeal. You or           course of making the benefit determination; or
your authorized representative may request it orally
or in writing. All necessary information, including     •	 Demonstrates compliance with processes and
UniCare’s decision, can be exchanged by telephone,         safeguards to ensure that claim determinations
facsimile or other similar method. To file an appeal       are made in accordance with the terms of the
for a claim involving urgent/concurrent care, you or       plan, applied consistently for similarly-situated
your authorized representative must contact                claimants; or
UniCare at the number shown on your identification      •	 Is a statement of the plan’s policy or guidance
card and provide at least the following information:       about the treatment or benefit relative to
•	 The identity of the claimant;                           your diagnosis.

•	 The date(s) of the medical service;                  UniCare will also provide you with any new
                                                        or additional evidence considered, relied upon,
•	 The specific medical condition or symptom;           or generated in connection with your claim.
•	 The provider’s name;                                 In addition, before you receive an adverse
                                                        benefit determination based on a new or
•	 The service or supply for which approval of          additional rationale, UniCare will provide you
   benefits was sought; and                             with the rationale.
•	 Any reasons why the appeal should be processed
   on a more expedited basis.




122
Appendix H


How Your Appeal Will Be Decided                        External Review
When UniCare considers your appeal, it will not rely   If the outcome of the internal appeal is adverse to
upon the initial benefit determination. The review     you, you may be eligible for an independent External
will be conducted by an appropriate reviewer who       Review pursuant to federal law.
did not make the initial determination and who does
                                                       Unless you are filing an Expedited External Appeal,
not work for the person who made the initial
                                                       you must first file an internal appeal with UniCare
determination.
                                                       before you can pursue an External Review. You must
If the denial was based in whole or in part on a       submit your request for External Review to UniCare
medical judgment, including whether the treatment      within four (4) months of the notice of UniCare’s
is experimental, investigational, or not medically     internal adverse determination.
necessary, the reviewer will consult with a health
                                                       A request for an External Review must be in writing
care professional who has the appropriate training
                                                       unless UniCare determines that it is not reasonable
and experience in the medical field involved in
                                                       to require a written statement. You do not have to
making the judgment. This health care professional
                                                       re-send the information that you submitted for
will not be one who was consulted in making an
                                                       internal appeal. However, you are encouraged to
earlier determination or who works for one who was
                                                       submit any additional information that you think is
consulted in making an earlier determination.
                                                       important for review.

Notification of the Outcome of                         For pre-service claims involving urgent/concurrent
                                                       care, you may proceed with an Expedited External
the Appeal
                                                       Review without filing an internal appeal or while
If you appeal a claim involving urgent/concurrent      simultaneously pursuing an expedited appeal
care, UniCare will notify you of the outcome of        through our internal appeal process. You or your
the appeal as soon as possible, but not later than     authorized representative may request it orally or in
72 hours after receipt of your request for appeal.     writing. All necessary information, including
                                                       UniCare’s decision, can be exchanged by telephone,
If you appeal any other pre-service claim, UniCare
                                                       facsimile or other similar method. To proceed with
will notify you of the outcome of the appeal within
                                                       an Expedited External Review, you or your
30 days after receipt of your request for appeal.
                                                       authorized representative must contact UniCare at
If you appeal a post-service claim, UniCare will       the number shown on your identification card and
notify you of the outcome of the appeal within         provide at least the following information:
30 days after receipt of your request for appeal.
                                                       •	 The identity of the claimant;
Appeal Denial                                          •	 The date(s) of the medical service;
If your appeal is denied, that denial will be          •	 The specific medical condition or symptom;
considered an adverse benefit determination. The
                                                       •	 The provider’s name;
notification from UniCare will include all pertinent
information set forth in the above section entitled    •	 The service or supply for which approval of
“Notice of Adverse Benefit Determination.”                benefits was sought; and
                                                       •	 Any reasons why the appeal should be processed
                                                          on a more expedited basis.




                                                                                                         123
Appendix H


All other requests for External Review should be       Requirement to File an Appeal before
submitted in writing unless UniCare determines
that it is not reasonable to require a written
                                                       Filing a Lawsuit
statement. Such requests should be submitted by        No lawsuit or legal action of any kind related to a
you or your authorized representative to:              benefit decision may be filed by you in a court of law
                                                       or in any other forum, unless it is commenced
UniCare State Indemnity Plan
                                                       within three years of the Plan’s final decision on the
P.O. Box 2011
                                                       claim or other request for benefits. If the Plan
Andover, MA 01810-0916
                                                       decides an appeal is untimely, the Plan’s latest
This is not an additional step that you must take in   decision on the merits of the underlying claim or
order to fulfill your appeal procedure obligations     benefit request is the final decision date. You must
described above. Your decision to seek External        exhaust the Plan’s internal Appeals Procedure before
Review will not affect your rights to any other        filing a lawsuit or taking other legal action of any
benefits under this health care plan. The External     kind against the Plan.
Review decision is final and binding on all parties
                                                       We reserve the right to modify the policies,
except for any relief available through applicable
                                                       procedures and time frames in this section upon
state laws.
                                                       further clarification from the Department of Health
                                                       and Human Services and the Department of Labor.




124
 Appendix I: Preventive Care Schedule
This chart shows the preventive services covered under your health plan as part of the Patient Protection and
Affordable Care Act (PPACA), the health care reform legislation that was passed in March 2010. PPACA
coverage of preventive services goes into effect July 1, 2011 for UniCare members. Benefits for the services
listed here are covered at 100% subject to the gender, age and frequency guidelines indicated.

  Preventive services do not generally include services intended to treat an existing illness, injury,
  or condition. Benefits will be determined based on how the provider submits the bill. Claims must
  be submitted with the appropriate diagnosis and procedure code in order to be paid at the 100%
  benefit level. If during your preventive services visit you receive services to treat an existing
  illness, injury or condition, you may be required to pay a copay, deductible and/or coinsurance
  for those covered services.

Please note that the preventive health care services, screenings, tests and vaccines listed are not
recommended for everyone. You and your health care provider should decide what care is most appropriate.



Preventive Service                             Gender
Recommended by
the U.S. Preventive                        Pregnant
Services Task Force              Men Women Women Children                 Age            Frequency
Abdominal aortic
aneurysm, screening               •       •                                       Every 12 months

Alcohol misuse
screening and behavioral          •       •          •          •                 Covered as a component
                                                                                  of your preventive exam
counseling intervention
Aspirin for the prevention
of cardiovascular disease         •       •                                       Subject to the Plan’s
                                                                                  pharmacy benefit
Asymptomatic bacteriuria
in adults, screening                                 •
Breast	cancer,	
screening (mammogram)                     •                             35 and Once between the ages
                                                                        40 and of 35 and 40; yearly after
                                                                         older age 40
Breast	and	ovarian	cancer	
susceptibility, genetic risk              •                                    Every 5 years

assessment and discussion
of	BRCA	mutation	testing	
(based on family risk factors)
Breastfeeding,	primary	
care interventions to                     •          •
promote breastfeeding
Cervical cancer, screening
(Pap smear)                               •          •          •                 Every 12 months

Chlamydial infection,
screening                                 •          •          •
                                                                                                          125
Appendix I


Preventive Service                            Gender
Recommended by
the U.S. Preventive                            Pregnant
Services Task Force               Men Women     Women Children    Age            Frequency
Colorectal cancer, screening
(Screenings include:              •     •                        50 and Every 5 years (60 months)
                                                                  older Every 12 months for fecal
colonoscopy, sigmoidoscopy,                                             occult blood test
procto-sigmoidoscopy,
barium enema, fecal occult
blood testing, laboratory
tests, and related services.)
Virtual	colonoscopy	or	virtual	
colonography is not covered
(see “Exclusions” section).
Depression (adults),
screening                         •     •         •                      Covered as a component
                                                                         of your preventive exam
Diet, behavioral counseling
in primary care to promote        •     •         •
healthy diet (adults with
hyperlipidemia and other
risk factors)
Evaluation and Management
services (E/M) (periodic                                  •                 T
                                                                         •			 wo	examinations,	
                                                                            including hearing
preventive examination/office                                               screening, while
visits) for children up to                                                  the newborn is in
age 19                                                                      the hospital.
                                                                            F
                                                                         •			 ive	visits	until	6	
                                                                            months of age; then
                                                                            E
                                                                         •			 very	two	months	until	
                                                                            18 months of age; then
                                                                            E
                                                                         •			 very	three	months	
                                                                            from 18 months of
                                                                            age until 3 years of
                                                                            age; then
                                                                            E
                                                                         •			 very	12	months	from	
                                                                            3 years of age until
                                                                            19 years of age.
Evaluation and Management
services (E/M) (periodic          •     •                                Every 12 months

preventive examination/office
visits) for adults age 19
and over
Gonorrhea, screening
                                  •     •         •                      Every 12 months

Gonorrhea, prophylactic eye
medication (newborns)                                     •
Gynecological examination
                                        •                                Every 12 months



126
Appendix I


Preventive Service                          Gender
Recommended by
the U.S. Preventive                          Pregnant
Services Task Force             Men Women     Women Children    Age            Frequency
Hearing loss in newborns,
screening                                               •
Hepatitis	B	virus	infection,	
screening                                       •
High blood pressure,
screening                       •     •         •                      Covered as a component
                                                                       of your preventive exam
HIV,	screening	(at	risk	and	
all pregnant women)             •     •         •       •
Iron deficiency anemia,
prevention (at risk 6- to                               •
12-month-old babies)
Iron deficiency anemia,
screening                       •     •         •       •
Lead screening, children
                                                        •
Lipid disorders in adults,
screening (cholesterol)         •     •         •                      Every 5 years

Major Depressive Disorders
in children and adolescents,                            •              Covered as a component
                                                                       of your preventive exam
screening
Obesity in adults, screening
                                 •    •                               Covered as a component
                                                                      of your preventive exam
Obesity in children,
screening                                               •             Covered as a component
                                                                      of your preventive exam
Osteoporosis in women,
screening (bone mineral               •                        40 and Every 2 years
                                                                older
density testing). Peripheral
bone mineral density testing
of the wrist, forearm, finger
and/or heel is not covered.
Phenylketonuria	(PKU),	
screening (newborn)                                     •
Prostate cancer, screening
(digital rectal exam and        •                                        D
                                                               50 and •			 igital	exam	–	Covered	
                                                                older    as a component of your
PSA test)                                                                preventive exam
                                                                         P
                                                                      •			 SA	test	–	Every	
                                                                         12 months
Rh (D) incompatibility,
screening                                       •
Sexually transmitted
infections, counseling          •     •         •       •              Covered as a component
                                                                       of your preventive exam



                                                                                              127
Appendix I


Preventive Service                           Gender
Recommended by
the U.S. Preventive                           Pregnant
Services Task Force              Men Women     Women Children   Age           Frequency
Sickle Cell disease,
screening (newborns)                                     •
Syphilis infection, screening
                                 •     •         •       •
Tobacco use and tobacco-
caused disease, counseling       •     •                                 C
                                                                      •			 ounseling	–	Covered	
                                                                         as a component of your
(including tobacco/nicotine                                              preventive exam
cessation drugs and                                                      D
                                                                      •			 rugs	and	deterrents	
deterrents)                                                              –	Subject	to	the	Plan’s	
                                                                         pharmacy benefit
Type 2 Diabetes Mellitus in
adults, screening                •     •         •
Visual	impairment	in	
children younger than                                    •            Covered as a component
                                                                      of your preventive exam
5 years, screening
Daily supplement of
folic acid                             •         •                    Subject to the Plan’s
                                                                      pharmacy benefit
Discuss chemoprevention
when at high risk for                  •                              Covered as a component
                                                                      of your preventive exam
breast cancer
Immunizations
                                 •     •         •       •
Additional covered screening
laboratory tests for adults      •     •         •                    When performed as a
                                                                      component of your
   H
•			 emoglobin	                                                       preventive exam
   U
•			 rinalysis
   C
•			 hemistry	profile	for	the	
   purpose of preventive
   screening includes the
   following:
     C
			–		 omplete	blood	count	
     (CBC)
     G
			–		 lucose
     B
			–		 lood	urea	nitrogen	
     (BUN)
     C
			–		 reatinine	transferase	
     alanine amino (SGPT)
     T
			–		 ransferase	asparate	
     amino (SGOT)
     T
			–		 hyroid	stimulating	
     hormone (TSH)




128
  Appendix J: Preferred Vendors
The UniCare State Indemnity Plan offers preferred vendors for certain services. As a member, using the
following preferred vendors will maximize your benefits. For those services marked below with a telephone
symbol (, you or someone on your behalf must call the Andover Service Center at (800) 442-9300 prior
to the start of these services to receive the maximum level of benefits.

( Durable Medical Equipment (DME)                       KCI                            (888) 275-4524
                                                        Service Area: National
(excluding medical supplies and therapeutic air flow    (wound-vacuum assisted
pressure relief mattresses)                             closures (V.A.C.) and
                                                        specialty mattresses
Note: No notification is required for oxygen and        & beds)
oxygen equipment.
                                                        National Seating
                                                        and Mobility
 Apria/Coram Healthcare           (800) 649-2422        Inside MA:                     (800) 660-0069
 Service Area: Nationwide                               Outside MA:                    (877) 482-2602
 (standard DME)                                         Service Area: Eastern MA,
 Baystate Home Infusion           (413) 794-4663        CA, CO, FL, GA, IN, NC,
 and Respiratory Services                               NY, OH, PA, SC,
 Service Area: Western MA                               TN, TX, WI
 (respiratory equipment only)                           (custom DME only)
 Boston Home Infusion             (781) 326-1986        New England Surgical, Inc.     (508) 675-7874
 Service Area: MA                                       (continuous passive
 (DME, respiratory therapy                              motion only)
 and home infusion)                                     Sleep Health Centers           (877) 753-3742
 Clinical One                     (800) 261-5737        Service Area: Eastern MA       or
 Service Area: Eastern MA         or                    (sleep studies, C-PAP and      (781) 271-0588
 (standard DME and                (781) 331-6856        Bi-PAP machines, and
 respiratory equipment)                                 related supplies)
 EBI, LP                          (800) 524-0677        Total Sleep Therapies DBA      (866) 852-5433
 Service Area: Nationwide                               Trusted Life Care
 (bone stimulators,                                     Service Area: MA, RI,
 medication pumps, dynamic                              southern NH
 splints and CPM machines)                              (standard DME and
                                                        respiratory equipment)
 Hudson Home Health Care          (800) 321-4442
 Service Area: Western MA
 and CT
 (DME, excluding respiratory
 equipment)
 Independent Mobility             (413) 499-4846
 Service Area: Western MA,
 southern	VT,	Albany,	NY
 (standard DME)




                                                                                                        129
Appendix J


( Home Infusion Therapy                        ( Home Health Care
 Apria/Coram Healthcare       (800) 678-3442    Baystate VNA & Hospice        (413) 781-5070
 Baystate Home Infusion       (413) 794-4663    Berkshire VNA                 (413) 447-2862
 and Respiratory Services
                                                Centrus Home Care             (800) 698-8200
 Boston Home Infusion         (781) 236-1986
                                                Hallmark VNA                  (781) 338-7900
 Home Solutions               Canton:
                                                Partners HealthCare at        (781) 290-4200
                              (888) 660-1660
 Service	Area:	Boston	Metro,	                   Home – Home Care
 Cape Cod & the Islands       Falmouth:         Quaboag Valley VNA            (413) 283-9715
                              (888) 244-1227    and Hospice
 Southcoast Home,             (508) 984-0200    South Shore VNA               (781) 849-1710
 Hospice and Home
 Infusion                                       Southcoast Home,              (508) 984-0200
                                                Hospice and
                                                Home Infusion
( Therapeutic Air Flow Pressure                 Steward Home Care             (781) 551-5600
Relief Mattresses                               VNA and Hospice of            (413) 664-4536
                                                Northern Berkshire, Inc.
 Hill Rom, Inc.               (800) 638-2546    VNA Care Network              (781) 569-2888
 KCI Therapeutic Services     (888) 275-4524    and Hospice
                                                VNA Hospice Alliance of       (413) 584-1060
                                                Cooley Dickinson Hospital
Medical Supplies                                VNA of Boston                 (617) 426-6630
 Animas Diabetes Care, LLC    (877) 937-7867    VNA of New England
                                                Please call the Andover Service Center at
 ( Insulin Pumps                                (800) 442-9300 for more information.
 Byram Healthcare             (800) 649-9882
                                               If you have questions about using preferred
 Insulet Corporation          (781) 457-5000   vendors, contact the Andover Service Center at
 OmniPod® Insulin                              (800) 442-9300.
 Management System
 Medtronic/MiniMed, Inc.

 ( Insulin Pumps:             (800) 874-9858
 Diabetic Supplies:           (800) 726-3059
 Neighborhood Diabetes        (800) 937-3028
 Shoppe
 Sterling Medical Services    (800) 229-0900
 (wound, urological, ostomy
 and diabetic supplies)




130
Index


A                                                        Book Symbol & 28
Acne-Related Services 46                                 Braces 12, 36, 39
Acupuncture 46, 47                                       Breast Pumps 46
Acute Care 29, 51
                                                         C
Adverse Benefit Determination 19, Appendix H
                                                         Calendar Year Deductible 6-7, 52
Air Conditioners/Purifiers 45, 48
                                                         Cardiac Rehabilitation 39, 52
Allowed Amount 12-13, 51
                                                         Cataracts (see Eyeglasses and Lenses)
Ambulance/Air Ambulance 35, 39, 49
                                                         CAT Scans (see High-Tech Imaging Services)
Ambulatory Surgical Centers (see Freestanding
 Ambulatory Surgical Centers)                            Chair Cars/Vans 46

Ancillary Services 29, 51                                Chemotherapy 31

Andover Service Center 1, 4                              Children’s Health Insurance Program (CHIP) 59,
                                                          Appendix G
Anesthesia 37, 39, 46, 49
                                                         Chiropractic Care 11, 21, 25, 32, 42, 55, 56
Annual Gynecological Visits (see Gynecological Visits)
                                                         Chronic Disease Hospitals/Facilities 30, 37, 56
Appeals Rights/Process 19, Appendix H
                                                         Circumcision 39
Application for Coverage 59
                                                         Claim Form Appendix E
Assistant Surgeon Services 38, 49, 51
                                                         Claims Inquiry 16
Athletic Trainers 48
                                                         Claims Review Process 16
Audiology Services 39
                                                         Claims Submission 14
Autism Spectrum Disorders 39, 51
                                                         Clinical Trials for Cancer (see Qualified Clinical
                                                          Trials for Cancer)
B
                                                         COBRA 62-65
Balance Billing 2, 12, 13, 51, 58
                                                         Cognitive Therapy 43, 47, 52
Benefit Highlights 28-36
                                                         Coinsurance 12
Bereavement Counseling 34, 44
                                                         Colonoscopies 48, Appendix I
Bill Checker Program 15, Appendix F
                                                         Commodes 45, 48
Birth Control (see Family Planning Services)
                                                         Community Choice Hospitals 2, 3, 5, 8, 9, 10-11, 12,
Blood Cholesterol Level 50, Appendix I
                                                          Appendix C
Blood Pressure Cuff 46
                                                         Complex Inpatient Procedures and Neonatal ICUs
Bone Density Testing Appendix I                           10, 29, 52, Appendix D
                                                         Computer-Assisted Communications Devices 47




                                                                                                              131
Index


Computer Symbol : 3, 28                        Discounts on Health-Related Products and Services 3

Contact Information 6                          Divorced 17, 52, 60, 62, 63, 65

Contact Lenses 36, 47, 50                      Durable Medical Equipment 3, 21, 25, 35, 41, 44-45,
                                                53, 56, Appendix J
Continued Stay Review 25
Continuing Coverage 60                         E
Conversion to Non-Group Health Coverage 65     Early Intervention Services for Children 35, 40, 53
Coordination of Benefits (COB) 16-18           Electrocardiograms (EKGs) 50
Copayments 8-11                                Eligibility/Enrollment 59-66
Coronary Artery Disease Secondary Prevention   Email Consultations 42, 47
 Program 27, 30, 52
                                               Emergency Services 10, 11, 21, 31, 32, 38, 53
Cosmetic Procedures/Services 46, 49, 52
                                               End Stage Renal Disease 19
Coverage Provisions 59-66
                                               Enrollee, definition of 53
Craniosacral Therapy 47
                                               Enrollee Assistance Programs 1, 6, 13, 36, 79-98
Crutches 39, 53
                                               Enteral Therapy 53
Custodial Care 41, 47, 52, 54, 55, 58
                                               Exclusions 47-48
CVS Caremark (see Prescription Drug Plan)
                                               Experimental or Investigational Procedures 41, 46,
                                                47, 53
D
                                               Eye Examinations 11, 36, 42
Deductibles 6-7
                                               Eyeglasses and Lenses 36, 47, 50
Dental Benefits 47, 49
Dependent, definition of 52                    F
Description of Covered Services 37-45          Family Planning Services 33, 40, 53
Designated Hospitals & Quality Centers for     Federal Early Retiree Reinsurance Program 106
 Transplants 2, 5, 10, 27, 30, 52
                                               Filing Deadline 15
Designated Hospitals for Select Complex
                                               Foot Care 43
 Procedures 2, 10, 29, 52, Appendix D
                                               Free or Low-Cost Health Coverage 59, 116
Diabetes 5, 39-40, Appendix I, Appendix J
                                               Freestanding Ambulatory Surgical Centers 9, 32,
Diagnostic Laboratory Testing 11, 29, 31, 33
                                                 38, 41, 49, 51, 53, 54
Dialysis 19, 39, 49
                                               Full-Time Students 6, 12, 61
Dietary Counseling 44, 50, Appendix I
Disclosure when Plan Meets Minimum Standards
 Appendix B




132
Index


G                                                       L
GIC Privacy Practices (see Privacy Practices)           Laboratory Testing (see Diagnostic Laboratory Testing)
Gynecological Visits 40, Appendix I                     Language Interpreter 4, 5
                                                        Legal Action 16
H
                                                        Lift Chairs 47
Health Insurance Portability and Accountability Act
 (HIPAA) 6, 19, 104                                     Limitations 49-50

Hearing Aids 36, 40, 47                                 Long-Term Care Hospitals/Facilities 30, 37, 56

Hearing Screenings 39, 40, 43, Appendix I               Low-Cost Coverage (see Free or Low-Cost
                                                         Health Coverage)
High-Tech Imaging Services 11, 29, 31, 33, 53
HIPAA Portability Rights 6, 19, 104                     M
Home Health Care 3, 12, 21, 25, 34, 40-41, 42, 54,      Magnetic Resonance Imaging (MRI) (see High-Tech
 Appendix J                                              Imaging Services)
Home Infusion Therapy 3, 21, 25, 34, 54,                Mammograms Appendix I
 Appendix J
                                                        Managed Care Program 20-27
Home Post-Delivery Care 120
                                                        Manipulative Therapy 21, 25, 42, 47, 55
Hospice 34, 43-44, 46, 47, 50, 54, 57, Appendix J
                                                        Maternity 21, 24, 120
Hospital, Inpatient 8, 10, 12, 24, 29, 37, Appendix D
                                                        MedCall Nurse Information Line 4

I                                                       Medical Case Management 4, 5, 26

ID Card 3, 5, 13                                        Medically Necessary, definition of 55

Immunizations Appendix I                                Medicare Coverage 18-19, 47, 54, 58, 59, 102-103

Incontinence 22, 47                                     Member, definition of 55

Incurred Date, definition of 54                         Mental Health Parity 7, 52

Infertility Treatment 41, 47, 50, 54, 55                Member Care Specialist 2, 4-5, 20, 55

Inpatient Hospital (see Hospital, Inpatient)            Mental Health/Substance Abuse Services 1, 6, 12,
                                                         13, 36, 47, 52, 79-98
Internet Providers 47
                                                        Midwife Services 39, 56, 120
Interpreting and Translating Services 4, 5
                                                        Molding Helmets 47
In Vitro Fertilization (see Infertility Treatment)
                                                        MRI (see High-Tech Imaging Services)




                                                                                                           133
Index


N                                                         Preferred Vendors 3, 5, 13, 25, 34, 35, 45, 56,
                                                           Appendix J
Notice of Privacy Practices (see Privacy Practices)
                                                          Prescription Drug Coverage and Medicare 102-103
Notification Requirements 20-24
                                                          Prescription Drug Plan 1, 6, 36, 39, 67-78
Nurse Practitioners 9, 11, 42, 49, 56, 57
                                                          Preventive Care 33, 42, 46, Appendix I
Nursing Homes 50, 54, 55
                                                          Primary Care Physicians 1, 9, 11
Nutritional Counseling/Therapy (see Dietary
 Counseling)                                              Privacy Practices 6, 19, 100-101
                                                          Private Duty Nursing 34, 42, 48
O
                                                          Private Room 29
Occupational Injury 46, 55
                                                          Prostate-Specific Antigen (PSA) Test Appendix I
Occupational Therapy 11, 21, 26, 31, 32, 40, 42, 55
                                                          Prostheses 12, 36, 38, 42, 47, 49, 56, 120
Office Visits 1, 2, 11, 33, Appendix I
                                                          Proton Emission Tomography (PET) Scans (see
Online Access to Health and Plan Information 3             High-Tech Imaging Services)
Orthotics 42, 50, 56                                      Provider Reimbursement 13
Osteopathic Manipulation 21, 25, 42, 55
                                                          Q
Out-of-Pocket Maximum 12
                                                          Qualified Clinical Trials for Cancer 45, 46, 56
Out-of-State Providers 2, 3, 13
                                                          Quality Centers and Designated Hospitals for
Outpatient Medical Care 31-32                              Transplants (see Designated Hospitals & Quality
Outpatient Surgery 9, 11, 12, 31, 38, 53                   Centers for Transplants)

Oxygen 21, 22, 25, 42, 48, 53, Appendix J
                                                          R
P                                                         Radiation Therapy 22, 31, 42

Pap Smear Test (see Gynecological Visits)                 Radioactive Isotope Therapy 42, 58

Patient Advocates 4, 5, 20, 24-26                         Radiology 11, 29, 31, 33, 37

Personal Emergency Response Systems (PERS) 36,            Reconsideration Process 26
 44                                                       Reconstructive and Restorative Surgery 38, 57, 120
PET Scans (see High-Tech Imaging Services)                Religious Facilities 48
Physical Exams 42, Appendix I                             Request and Release of Medical Information 19
Physical Therapy 11, 21, 25, 31, 32, 40, 42, 47, 48, 56   Rescission, definition of 57
Physician Services 1, 32, 37, 42                          Respite Care 44, 50, 57
Physician Tiering 1, 2, 8, 9, 11, 13-14, 56               Restrictions on Legal Action 16
Plan Definitions 51-58




134
Index

Retail Medical Clinics 11, 33, 42, 50, 57                  Thermal Therapy Devices 48
Right of Recovery 18                                       Tiering, Physician (see Physician Tiering)
Right of Reimbursement 16                                  Transitional Care Hospitals/Facilities 30, 37, 56
                                                           Transplants 10, 21, 27, 30, 43, 52
S
                                                           Travel 2, 12-13, 58
Selected Procedure Review 22-24, 26
                                                           Travel Access Providers 2, 12-13, 58
Sensory Integration Therapy 48
Serious, Preventable Adverse Health Care Events 48         U
Shower Chairs 45, 48, 53                                   Uniformed Services Employment and
                                                            Reemployment Rights Act (USERRA) 105
Skilled Care 37, 40-41, 42, 55, 57, 58
                                                           United Behavioral Health (see Mental Health/
Skilled Nursing Facilities (SNF) 30, 37, 50, 55, 56, 58
                                                            Substance Abuse Services)
Smoking Cessation 50, Appendix I
                                                           Urgent Care 2, 12, 42, 53, 57, 58
Special Enrollment Condition 60
                                                           Utilization Management Program 1, 4, 5, 20, 24
Specialty Care Physicians 11, 13
SPECT Scans (see High-Tech Imaging Services)               V
Speech-Language Pathology Services 31, 37, 39, 40,         Virtual Colonoscopies (see Colonoscopies)
 41, 43, 44, 53                                            Vision Care 11, 36, 42
Sub-Acute Care Hospitals/Facilities 30, 37, 56             Visiting Nurses 21, 34, 58
Substance Abuse Services (see Mental Health/
 Substance Abuse Services)                                 W
Surface Electromyography (SEMG) 48                         Website Addresses 6

Surgical Services 9, 11, 12, 31, 32, 38, 47, 48, 49, 50,   Weight Loss Programs 50
 57, 120                                                   Whirlpools 45, 48

T                                                          Wigs 36, 43, 50

Telecommunications Device for the Deaf (TDD) 5, 6          Workers Compensation (see Occupational Injury)

Telephone Consultations 42, 48                             Worksite Evaluations 48

Telephone Numbers, Important 6                             X
Telephone Symbol ( 2, 28, Appendix J                       X-Rays (see Radiology)
Temporomandibular Joint (TMJ) Disorder 50, 58




                                                                                                               135
UniCare State Indemnity Plan
Andover Service Center
P.O. Box 9016
Andover, MA 01810-0916
(800) 442-9300
www.unicarestateplan.com       21769MAMENUNC 10/11

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:17
posted:3/21/2012
language:English
pages:142