the archdiocese of new york benefits administration resource guide

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Summary of Benefits UnitedHealthcare Choice Plus Archdiocese of New York Active Plan for Clergy, Religious, Seminarians, and Lay Employees Effective January 1, 2006, if you have any questions please call UnitedHealthcare Member Services at 1-800-736-1264 or register on myuhc.com to get detailed information on your coverage. Choice Plus plan gives you the freedom to see any Physician or other health care professional from the Network, including specialists, without a referral. With this plan, you will receive the highest level of benefits when you seek care from a network physician, facility or other health care professional. In addition, you do not have to worry about any claim forms or bills. You also may choose to seek care outside the Network, without a referral. However, you should know that care received from a non-network physician, facility or other health care professional means a higher deductible and coinsurance. We recommend that you ask the non-network physician or health care professional about their billed charges before you receive care. Some of the Important Benefits of Your Plan: • You have access to a Network of physicians, facilities and other health care professionals, including specialists, without designating a Primary Physician or obtaining a referral. • Benefits are available for office visits and hospital care, as well as inpatient and outpatient surgery. • United Healthcare’s Nurseline connects you to registered nurses and a library of recorded programs on important health topics 24 hours a day, 7 days a week, from anywhere in U.S. • We offer the Language Line Services so that you can talk with us in 140 different languages. Just call customer service and ask for an interpreter. • Emergencies are covered anywhere in the world. • Care Coordination SM services are available to help identify and prevent delays in care for those who might need specialized help. • The tools and information at myuhc.com are practical and personalized so you can get the most out of your benefits. Register at myuhc.com and connect to current information about your benefits and health care interests. • Cancer Resource Services provides information on comprehensive cancer treatment services. Benefit from using one of our Centers of Excellence by calling 1-866-936-6002.
Choice Plus Benefits Summary Types of Coverage Network Benefits / Copayment Amounts Non-Network Benefits / Copayment Amounts This Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover all of your health care expenses. More complete descriptions of Benefits and the terms under which they are provided are contained in the Summary Plan Description that you will receive upon enrolling in the Plan. If this Benefit Summary conflicts in any way with the Summary Plan Description issued to your employer, the Summary Plan Description shall prevail. Terms that are capitalized in the Benefit Summary are defined in the Summary Plan Description. Network Benefits are payable for Covered Health Services provided by or under the direction of your Network physician. *Prior Notification is required for certain services. Annual Deductible: $150 per Covered Person per calendar year, not to exceed $300 for all Covered Persons in a family. Cross applies with out of network deductible. Out-of-Pocket Maximum: $1,200 per Covered Person per calendar year, not to exceed $2,400 per family. The Out-of-Pocket Maximum does not include the Annual Deductible. Cross applies with out of network out of pocket maximum. Maximum Plan Benefit: No Maximum Plan Benefit. MEMBER PAYS 1. Ambulance Services - Emergency only Ground Transportation: 10% of Eligible Expenses after satisfying deductible Air Transportation: 10% of Eligible Expenses after satisfying deductible 2. Dental Services - Accident only (must begin within 6 months of injury) Annual Deductible: $300 per Covered Person per calendar year, not to exceed $600 for all Covered Persons in a family. Cross applies with in network deductible. Out-of-Pocket Maximum: $2,000 per Covered Person per calendar year, not to exceed $4,000 per family. The Out-of-Pocket Maximum does not include the Annual Deductible. Cross applies with in network out of pocket maximum. Maximum Plan Benefit: $1,000,000 per Covered Person. MEMBER PAYS Same as Network Benefit 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 3. Durable Medical Equipment (the purchase or 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible rental of prescribed equipment is covered, including needed replacement and repairs) 4. Emergency Health Services $50 per visit (copay waived if admitted) True Emergencies - Same as Network Benefit Non-Emergency Visits - 30% of Eligible Expenses after satisfying deductible *Notification is required if results in an Inpatient Stay. 5. Refractive Eye Examinations No Coverage No Coverage 6. Home Health Care Network and Non-Network Benefits are limited to 200 per calendar year combined in and out of network. 7. Hospice Care No annual maximum. 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 8. Hospital - Inpatient Stay 10% of Eligible Expenses after satisfying deductible *30% of Eligible Expenses after satisfying deductible 9. Injections Received in a Physician’s Office $25 per visit 30% of Eligible Expenses after satisfying deductible 10. Maternity Services Delivery - 10% of Eligible Expenses after satisfying deductible Prenatal visit – 100% after $25 copay (copay applies to first prenatal visit only) Outpatient Diagnostic Services - 10% of Eligible Expenses after satisfying deductible Mother’s Hospital Charge - 10% of Eligible Expenses after satisfying deductible Newborn Nursery Charge - 10% of Eligible Expenses waive deductible 11. Outpatient Surgery, Diagnostic and Therapeutic Services Delivery - 30% of Eligible Expenses after satisfying deductible Prenatal visit – 30% of Eligible Expenses after satisfying deductible Outpatient Diagnostic Services - 30% of Eligible Expenses after satisfying deductible Mother’s Hospital Charge - 30% of Eligible Expenses after satisfying deductible Newborn Nursery Charge - 30% of Eligible Expenses after satisfying deductible *Notification is required out of network if Inpatient Stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery. Outpatient Surgery 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible Outpatient Diagnostic Services For lab and radiology/Xray: 10% of Eligible Expenses after satisfying deductible For mammography testing: 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible Outpatient Diagnostic/Therapeutic Services - CT 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible Scans, Pet Scans, MRI and Nuclear Medicine Outpatient Therapeutic Treatments 10% of Eligible Expenses after satisfying deductible 30% of Eligible Expenses after satisfying deductible
Page 1 and 2: THE ARCHDIOCESE OF NEW YORK BENEFIT
Page 3 and 4: THE ARCHDIOCESE OF NEW YORK BENEFIT
Page 5 and 6: Section I Important Information
Page 7 and 8: NEW EMPLOYEE CHECKLIST The followin
Page 9 and 10: BENEFITS ADMINISTRATOR RESOURCE CON
Page 11 and 12: VENDOR CONTACT PHONE WEBSITES POLIC
Page 13 and 14: RULES FOR MEMBER GROUPS PARTICIPATI
Page 15 and 16: 5. All clergy and religious orders
Page 17 and 18: BENEFIT ELIGIBILITY OUTLINE -5-
Page 19 and 20: BENEFITS ELIGIBILITY EFFECTIVE DATE
Page 21 and 22: DIVISION CLAIM CODES -6-
Page 23: Group 3000 - New York State Continu
Page 27 and 28: HEALTH INSURANCE PORTABILITY & ACCO
Page 29 and 30: Revised: January 1, 2006 Effective:
Page 35 and 36: ARCHDIOCESE OF NEW YORK AUTHORIZATI
Page 37 and 38: AUTHORIZATION FOR THE USE AND DISCL
Page 39 and 40: HOW TO ENROLL IN THE GROUP HEALTH B
Page 41 and 42: Annual Salary (Benefit Administrato
Page 43 and 44: ARCHDIOCESE OF NEW YORK Group Healt
Page 47 and 48: STATEMENT OF DEPENDENT ELIGIBILITY
Page 49: THE ARCHDIOCESE OF NEW YORK SUMMARY
Page 53 and 54: UnitedHealthcare Additional Benefit
Page 55 and 56: THE ARCHDIOCESE OF NEW YORK SUMMARY
Page 57 and 58: Choice Plus Benefits Summary Types
Page 59 and 60: UnitedHealthcare Additional Benefit
Page 61 and 62: THE ARCHDIOCESE OF NEW YORK SUMMARY
Page 63 and 64: Medicare Supplemental Plan Benefits
Page 65 and 66: Exclusions UnitedHealthcare Except
Page 67: HOW TO FILE A MEDICAL CLAIM There a
Page 70 and 71: HOW TO FILE A CLAIM FOR PRESCRIPTIO
Page 72 and 73: FILL IN FOR UP TO TWO PEOPLE WHO WI
Page 74 and 75: STEP 2 Submission Requirements: You
Page 77 and 78: ARCHDIOCESE OF NEW YORK BENEFITS TR
Page 79 and 80: ★ ★ REEMPLOYMENT RIGHTS YOUR RI
Page 81 and 82: ARCHDIOCESE OF NEW YORK NOTICE OF G
Page 83 and 84: Archdiocese of New York Group Healt
Page 87 and 88: GROUP HEALTH BENEFITS FOR EMPLOYEES
Page 93 and 94: ___________________________________
Page 95 and 96: Section VI Administration of Life,
Page 97 and 98: ARCHDIOCESE OF NEW YORK Life and Ac
Page 99: HOW TO FILE A CLAIM FOR BASIC GROUP
Page 115 and 116:
GROUP LIFE INSURANCE BENEFITS FOR E
Page 122 and 123:
GROUP LIFE INSURANCE BENEFITS FOR E
Page 128 and 129:
Section VII Administration of Short
Page 130 and 131:
HOW TO FILE A CLAIM FOR NEW YORK ST
Page 132 and 133:
NOTICE AND PROOF OF CLAIM FOR DISAB
Page 134 and 135:
NOTICE AND PROOF OF CLAIM FOR DISAB
Page 136 and 137:
ARCHDIOCESE OF NEW YORK Benefit Pla
Page 148 and 149:
Section IX Administration of Dental
Page 150:
CIGNA Dental for Religious and Cler
Page 153 and 154:
ARCHDIOCESE OF NEW YORK CIGNA Denta
Page 155:
HOW TO FILE A DENTAL CLAIM There ar
Page 160 and 161:
DAVIS VISION CARE VISION CARE BENEF
Page 162 and 163:
ARCHDIOCESE OF NEW YORK Benefit Hig
Page 164 and 165:
HOW TO FILE A VISION CARE CLAIM (Cl
Page 166 and 167:
Section XI Administration of Volunt
Page 168 and 169:
ARCHDIOCESE OF NEW YORK SUPPLEMENTA
Page 170 and 171:
INTERNAL USE ONLY Institution Name:
Page 172 and 173:
PERSONAL HEALTH APPLICATION Thank y
Page 174 and 175:
Employee: First Name_______________
Page 176 and 177:
Employee: First Name_______________
Page 178:
IMPORTANT NOTICE The Archdiocese of
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