It's Your Choice 2013 - Decision Guide (ET-2128d-13) - ETF

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UnitedHealthcare of Wisconsin Southeast (800) 357-0974 or (866) 873-3903 during the Enrollment Period myuhc.com Overall Quality Rating See Report Card section What’s New for 2013 Each member who completes the online health risk assessment with biometric screening will receive a $75 gift card. Innovative resources such as: the health care cost estimator tool, myHCE, to assist in decisions with more than 120 care paths; a new Health & Wellness tab personalized for individual goals and support; also check out our new Health4me App for access on the go! Provider Directory Go to welcometouhc.com/state, Find a doctor/hospital. Call customer service at (800) 357-0974 (current member) or (866) 873-3903 for a paper copy. Referrals and Prior Authorizations You do not need a referral to see a physician/hospital in the network. If a specific covered health service is not available from a network physician/ hospital, your network physician must notify UnitedHealthcare (UHC) Care Coordination to request a “Network Gap Exception.” In addition, you are responsible for notifying UHC’s Care Coordination before obtaining services for dental/oral surgery or within 24 hours (or as soon as possible) of an emergency admission to a non-network hospital. You and your physician will be notified in writing of UHC’s decision and coverage determination. Care Outside Service Area For emergency or urgent care, please contact UHC at (800) 357-0974 as soon as possible. Care other than emergency or urgent care is not covered outside of the service area. Follow-up care will need to be completed back in the service area with your participating provider (see map at right). Mental and Behavioral Health Services Members must call United Behavioral Health (UBH) at (800) 851-5188 for an initial assessment Qualified Plan and for authorization Non-Qualified Plan for any and all See Glossary for definitions services with network providers. Please note: After standard business hours, UBH can only manage inpatient benefits and authorizations. Dental Benefits (Contact plan for full details.) Preventive Services: Covered at 100%: exams two times per calendar year, bitewing X-rays, cleanings, fluoride treatments and sealants, complete series or panorex X-rays. Restorative Services: Covered at 50% after deductible ($50 individual/$100 family): amalgam and composite resin restorations, general anesthesia and space retainers. No coverage for major restorative services. Annual Benefit Maximum: $1,000 per person per calendar year. Orthodontics: Covered at 50% for dependents younger than age 19; up to an individual orthodontic lifetime maximum of $1,200. Dental Network: Open dental network to go to a dentist of your choice. Charges are payable up to UHC’s maximum allowable fee schedule. Health Risk Assessment Information for Enrolled Members at: myuhc.com, log on, then select “Health Risk Assessment” or call one of the numbers above Decision Guide Page 52
Unity Health Insurance – Community (800) 362-3310 chooseunityhealth.com Overall Quality Rating See Report Card section What’s New for 2013 Adult members will earn $25 for taking an online health risk assessment (HRA). Go to unitymychart.com, log in, select Wellness Programs and then Take an HRA. Earn another $25 when specific biometrics are submitted to Unity. To read more about this and quarterly wellness challenges visit chooseunityhealth.com and select Health Risk Assessment (HRA) and Wellness under the Unity Difference. Want to learn more about how health insurance works? Check out Unity’s new online Resource Center at chooseunityhealth.com/resourcecenter where you will find educational videos, tools and other information to help you better understand health insurance. You continue to have guaranteed access to UW Health specialists. Provider Directory Go to chooseunityhealth.com and select Find A Doctor. Here you will find links to the 2013 Community Network Provider Directory (PDF) and the Community Network provider search function. You may also call (800) 548- 6489 to request a copy of the Community Network Provider Directory. Referrals and Prior Authorizations Written referral requests are required to see providers not in the Community Network. Prior authorizations are required for certain services. See the Community Network Provider Directory for Qualified Plan Non-Qualified Plan more information. Your See Glossary for definitions doctor must submit the request, and Unity will notify you in writing of the decision. Care Outside Service Area Call Unity at (800) 362-3310 within three business days after receiving emergency or urgent care services from an out-of-network provider. All other care from out-of-network providers requires a written referral request as described above. Mental and Behavioral Health Services Before getting services, you must call UW Behavioral Health at (800) 683-2300. Assistance is available 24 hours a day. Dental Benefits No routine dental coverage provided. Health Risk Assessment Information for Enrolled Members at: chooseunityhealth.com, sign-in for “My Chart,” then select “Wellness Programs” and “Health Risk Assessment” Decision Guide Page 53
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It’s Your Choice: 2013 Decision G
Page 3 and 4: Table of Contents Choose Wisely....
Page 5 and 6: Choose Wisely Sheboygan Fiesta Hisp
Page 7 and 8: Choose Wisely Standard Plan Benefit
Page 9 and 10: FREQUENTLY ASKED QUESTIONS IT’S Y
Page 11 and 12: Choose Wisely dependents through th
Page 13 and 14: Choose Wisely back of this Guide or
Page 15 and 16: Choose Wisely When you use in-netwo
Page 17 and 18: Choose Your Health Plan radiology (
Page 19 and 20: Local Government Employees and Annu
Page 21 and 22: LOCAL HEALTH PLAN TIERS Choose Your
Page 23 and 24: Choose Your Health Plan HEALTH PLAN
Page 25 and 26: Comparison of Benefit Options BENEF
Page 27 and 28: Comparison of Benefit Options BENEF
Page 29 and 30: Choose Your Health Plan coordinated
Page 31 and 32: Health Plan Features - At a Glance
Page 33 and 34: Anthem Blue Preferred - Northeast N
Page 35 and 36: Anthem Blue Preferred - Southeast N
Page 37 and 38: Dean Health Plan Inc. (800) 279-130
Page 39 and 40: Group Health Cooperative of South C
Page 41 and 42: Health Tradition Health Plan (877)
Page 43 and 44: Humana - Eastern (800) 4humana [(80
Page 45 and 46: Medical Associates Health Plans (80
Page 47 and 48: MercyCare Health Plans (800) 895-24
Page 49 and 50: Physicians Plus (608) 282-8900 or (
Page 51 and 52: Standard Plan Administered by WPS H
Page 53: UnitedHealthcare of Wisconsin North
Page 57 and 58: WEA Trust PPO - East (800) 279-4000
Page 59 and 60: WPS Metro Choice Northwest (800) 63
Page 61 and 62: Choose Quality HEALTH PLAN REPORT C
Page 63 and 64: Quality Composite Rating Chart Unde
Page 65 and 66: CAHPS ® Composite Rating Chart Und
Page 67 and 68: Choose Quality GRIEVANCE AND COMPLA
Page 69 and 70: Choose Quality OTHER QUALITY INFORM
Page 71 and 72: NAVITUS HEALTH SOLUTIONS — Pharm
Page 73 and 74: NAVITUS MedicareRX (PDP)— Pharmac
Page 75 and 76: For Medicare eligible, retired, dis
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Page 79 and 80: myETF Benefits System Instructions
Page 81 and 82: Department of Employee Trust Funds
Page 83 and 84: ETF Use Only State of Wisconsin Dep
Page 85 and 86: Applicant Name Social Security Numb
Page 87 and 88: DUPLICATE APPLICATION FOR YOUR RECO
Page 89 and 90: DUPLICATE APPLICATION FOR YOUR RECO
Page 91 and 92: Glossary Coinsurance: Your share of
Page 93 and 94: Glossary In-network Copayment: A fi
Page 95 and 96: Glossary Preventive Services: Routi
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Page 99 and 100: Health Plan Contact Information Ant
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