2013 NYUHC Medical SPD.pub

Quality Health Care Is Valued
Your Medical Plan
SUMMARY PLAN DESCRIPTION
New York
NYU
University
Hospitals
School
Center
of Medicine
Information About the Health Plans
ELIGIBILITY
Eligibility for Medical and Prescription Drug Plan Coverage
Eligible Dependents of NYUHC Employees
YOUR CHOICES
Medical Plan Options
The Prescription Drug Plan Options
Important Considerations When Selecting A Medical Plan
Types of Benefit Payments & Costs Under the PPO Plans
Selecting Medical care Under an EPO or HMO Plan
Important Considerations Regarding Prescription Drug Benefits
Enrollment for Medical and Prescription Coverage
Providing Medical and Prescription Drug Coverage For Dependents
Changing Coverage During the Year
Declining Coverage vs. Defaulting to Limited Coverage
THE UNITEDHEALTHCARE PPO PLANS
Claims Information
Coordination of Benefits Under the UHC PPO Plans
Continuation of Health Coverage Under the UHC PPO Plans
Glossary for the UHC PPO Plans
Benefit Summaries for the UHC PPO Plans
THE EXCLUSIVE PROVIDER ORGANIZATION (EPO) & HEALTH MAINTENANCE ORGANIZATION (HMO)
Benefit Summaries for the EPO & HMO Plans
HOSPITAL DISCOUNT FOR EMPLOYEES OF NYUHC
THE PRESCRIPTION DRUG PLAN
The Preferred Drug List
Filling Your Prescription Drug Medications
Prescription Drug Costs
Prescription Drugs Requiring Prior Authorization
Plan Limits on Lifestyle Drugs
Prescription Drugs Not Covered Under the Plan
Coordination of Benefits
Filing Claims and Appeals
CONTINUATION OF HEALTH COVERAGE DURING LEAVES OF ABSENCE
WHEN HEALTH COVERAGE ENDS
CONTINUATION OF HEALTH COVERAGE UNDER COBRA
PRIVACY PRACTICES REGARDING YOUR HEALTH INFORMATION
THE WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998
YOUR RIGHTS UNDER USERRA
IMPORTANT LEGAL INFORMATION
ABOUT THE HEALTH BENEFIT PLANS
NYUHC provides eligible employees with competitive and comprehensive medical and prescription drug plan coverage. The quality and affordability of the plans play a significant role in the ongoing commitment to retain and attract
preeminent diverse talent.
NYUHC recognizes diversity in workforce needs by offering medical plans that allow for flexibility and easy access to
medical care according to individual needs and lifestyles. The result is reflected in the medical and prescription drug
plans offered through two types of benefit programs- BeneFlex and BasicCare.
BeneFlex and BasicCare share a common benefits platform while still offering eligible employees a variety of options
to access medical care.
The medical and prescription drug benefits offered under both programs provide eligible employees the following:
Q
F
UALITY NYUHC continually evaluates insurance carriers and benefit plans for quality- quality of benefits, and customer service assistance .
LEXIBILITY NYUHC recognizes that diverse people have different needs and that one standard medical plan approach will not accommodate everyone’s needs. The medical plan options provide eligible
employees with the flexibility to choose the plans and coverage levels that suit individual needs as well
those of their eligible dependents.
A
E
FFORDABILITY
NYU School of Medicine together with NYU Hospitals Center, command more leverage
and negotiating power in the benefits marketplace to purchase valuable, comprehensive medical plans at
cost-effective rates.
MPLOYEE SATISFACTION Participants in NYU Hospitals Center Health & Welfare Plan decide
which options they want. They contribute towards the cost of coverage, decide how to use and maximize
their benefits. As your employer, NYUHC wants to ensure that the plan options offered provide satisfaction.
ELIGIBILITY FOR MEDICAL AND PRESCRIPTION DRUG
PLAN COVERAGE
Your employee group (see sections below) determines your participation eligibility in either the
BeneFlex OR BasicCare program . Employees cannot enroll for medical and prescription
drug coverage under both benefit programs.
BeneFlex Eligible Employees of NYU Hospitals Center (NYUHC)
The following employees compensated by NYUHC or NYUHJD are eligible to participate in the BeneFlex Program:
Regular salaried non-bargaining union Staff with base hours of at least 17.5 hours per week (paid by NYUHC or
NYUHJD)
Regular salaried Local One Security Staff with base hours of at least 17.5 hours per week.
BasicCare Eligible Employees of NYU Hospitals Center (NYUHC)
The following NYUHC and NYUHJD Staff are eligible to participate in the BasicCare Program*:
Psychology Interns
House Staff
Please note that each group may be eligible for different benefits
LEVELS OF COVERAGE
Under the BeneFlex and BasicCare programs, eligible employees are offered the following levels of
coverage for medical and prescription drug plan benefits:
Employee Only
Employee + one eligible dependent
Employee + two eligible dependents
Please note that the level of coverage you elect for medical and prescription drug coverage must be the same
and the same dependents must be covered under both the medical and prescription drug plans.
ELIGIBLE DEPENDENTS OF NYUHC EMPLOYEES
The following dependents of eligible employees may be covered under the medical and prescription drug plan options under either the BeneFlex or BasicCare programs as outlined below .
Note: Upon enrollment you will be required to provide documentation supporting the relationship to the
dependent(s) you intend to cover or waive from coverage if you are eligible for waiver dollars under either program.
A Spouse
A Domestic Partner*. A Domestic Partner under the Plan is defined as a person who has a single dedicated relationship with the Employee that contains the following elements:
Both the Employee and Domestic Partner are at least eighteen (18) years of age and mentally competent
to consent to contract.
The relationship is intended to last indefinitely.
In addition, the Employee and Domestic Partner must certify that they are domestic partners and
eligible for medical benefit coverage as domestic partners under the NYUHC Health & Welfare Plan
in accordance with the following criteria in order of relevance (i.e the first and second options are to
be chosen in the order of relevance. The third option is only available if you cannot satisfy either
Option 1 or Option 2):
Option 1: The Employee and Domestic Partner must have a Certificate of Domestic Partnership issue by the
Office of the City Clerk of the City of New York (the certified copy of the original must be presented to the
NYULMC Benefits Services Department and a copy will be made for the record); OR
Option 2: The Employee and Domestic Partner must have a marriage certificate; domestic partner certificate;
or proof of a civil union not recognized by the State of New York, but lawfully recognized in another jurisdiction, including the City of New York (the certified copy of the original must be presented to the NYULMC
Benefits Services Department and a copy will be made for the record); OR
Option 3: If the Employee and Domestic Partner is not eligible for a Certificate of Domestic Partnership from
the City of New York and do not have a marriage certificate, domestic partnership registration or proof of a
civil union from a jurisdiction outside the City of New York, they must attest to the following:
That they are each other’s sole domestic partner and intend to remain so indefinitely.
That neither partner is married or in another domestic partnership
That both partners are at least eighteen (18) years old and mentally competent to consent to a contract
That both partners are not related by blood to a degree of closeness which would prohibit legal marriage
in the state in which they legally reside if one partner is of the opposite sex.
That both partners are jointly responsible for each other’s common welfare and share financial obligations.
Joint responsibility for each other’s common exclusive mutual welfare and shared financial obligations must be
demonstrated by the existence of three of the following:
Joint mortgage or lease
Designation of domestic partner as primary beneficiary of employee’s life insurance policy
Designation of domestic partner as primary beneficiary in employee’s will
Joint ownership of motor vehicle
Joint checking account
Joint credit account
Domestic partner registration with a state or municipal government
*Important Notes on Domestic Partner Coverage :
NYU Hospitals Center expanded the definition of an eligible dependent under the benefit plans to also include ‘opposite
gender’ domestic partner and the children of the employee’s partner effective August 1, 2006.
According to IRS regulations, payroll deductions for domestic partner benefits must be made with ‘after-tax’ contributions AND the value of this coverage is considered ‘taxable’ income. Therefore, employees who elect to cover their
domestic partner (and the domestic partner’s children, if any) will automatically be taxed on this coverage on their paychecks.
The exception to this is when a domestic partner qualifies as a dependent under section 152 of the IRS code,
which in that case, the benefits offered will be treated as if they were provided to any other qualified dependent.
This means the cost of the benefits offered to your domestic partner and/or your partner’s children will be deducted from
your pay on a ’pre-tax basis’ and the value of providing those benefits will NOT be taxed.
Section 152 of the IRS code stipulates that a person can be classified as a “qualified” dependent for tax purposes if they satisfy certain criteria.
Please consult your tax advisor to determine whether or not you qualify for this exception.
Documentation will be required to establish the relationship of your domestic partner (and his/her children) and must be
submitted to the NYULMC Benefits Services Department at the time of enrollment of your partner for coverage.
To establish the relationship of your domestic partner, you will complete and submit the following to the
NYULMC Benefit Services Department :
Completed ‘Statement of Domestic Partnership Affidavit’ , AND
Certified copies of an original supporting documentation from one of the three (3) options as outlined on page 8
(note: these options are also outlined in the ‘Statement of Domestic Partnership Affidavit’) , AND
Valid identification for your domestic partner from the following to include any one of the following:
birth certificate, passport, driver’s licence, non-driver’s ID, military ID or immigration card.
In addition, to establish the relationship of your domestic partner’s children, you will need to also submit any of
the following to Benefit Services at the time of enrollment to establish the relationship:
birth cerificates for your domestic partners child(ren)
legal adoption or legal guardianship papers for your domestic partner’s child(ren).
Please be advised that you must present original forms of the required supporting documentation to the
NYULMC Benefit Services Department. Copies of your originals will be made for the record.
A ‘Child’ is considered an eligible dependent under the Plan and the term applies to the
following:
A biological child or stepchild
A child of the Employee’s domestic partner who resides in the home that is shared by the Employee and the
Employee’s partner
A legally adopted child (a child is considered legally adopted on the earlier of the date of placement or the date
the legal adoption proceedings have commenced.)
A child related to an eligible Employee for which the employee has legal guardianship. The child must be mainly
dependent on the eligible Employee for care and support AND reside in the eligible Employee’s home.
Effective January 1, 2011, your child(ren) or registered domestic partner’s children are eligible to be covered under
the Plan until the end of the month in which the 26th birthday occurs. Coverage may be continued for your eligible
children up to any age, if they cannot support themselves because of a mental or physical disability (certification that
disability occurred before age 26 is required).
IMPORTANT NOTES REGARDING ELIGIBLE DEPENDENTS
Dependents of eligible Employees must permanently reside in the United States.
You cannot be covered (or be eligible for waiver dollars) under this plan as both an employee
and a dependent. This means if you and your spouse/domestic partner are both eligible NYUHC employees,
each of you must elect individual coverage, or only one of you may elect coverage for ‘Employee + one eligible
dependent’ (or elect ‘Family’ coverage if other eligible children are also being covered under the Plan).
QUALIFIED MEDICAL CHILD SUPPORT ORDERS
A Qualified Medical Child Support Order (QMCSO) is a medical child support order in a
judgment, decree or court order (including approval of a settlement agreement) issued by :
(a) a state court of competent jurisdiction, or (b) through an administrative process established
under State law, and has the force and effect of law under applicable State law, which either :
provides for child support with respect to a child of a participant (also referred to as “alternate recipient”)
under a group health plan, or provides for health benefit coverage for such a child, OR
enforces a law relating to medical child support required of the states under Section 1908 of the Social Security
Act (42 U.S.C §1396g-1).
A Qualified Medical Child Support Order (QMCSO) in compliance with section 609(a)(2)(A) of the
Employee Retirement Income Security Act (“ERISA”) must satisfy the following requirements:
It must be made under a State domestic relations law and relate to benefits under the participant’s group health
plan and clearly specify:
the name and last known address (if any) of the participant and the name and last known address of each child
covered by the order.
a reasonable description of the type of coverage to be provided by the plan to each such alternate recipient, or
the manner in which the type of coverage is to be determined;
the period to which the order applies; and
The QMCSO may not require the plan to provide any type or form of benefit, or any option not otherwise provided
under the plan(s) - except to the extent necessary to meet the requirements of a law relating to medical child support
described in Section 1908 of the Social Security Act.
NYUHC has procedures for determining the qualified status of medical child support orders and upon receipt of
such an order will follow these procedures in determining whether to approve the order as a QMCSO (the following section outlines the QMCSO procedures established by NYUHC).
Please be advised that neither the QMCSO procedures, or this explanation of the requirements for a qualified order
and any statement by NYUHC or its legal counsel does not constitute legal advice to participants or alternate recipients. Participants and alternate recipients should consult their own lawyer for legal advice concerning any medical
child support order.
Upon approval of a QMCSO, the Plan is required to pay benefits directly to the child, or to the child’s custodial parent
or legal guardian, pursuant to the terms of the order and to the extent it is consistent with the terms of the Plan.
If you have a medical child support order, you or your authorized representative must notify NYUHC , as
Plan Administrator. In addition, NYUHC will also notify you and the affected child if it receives a QMCSO
that applies to your benefits.
PROCEDURES FOR DETERMINING QUALIFIED STATUS OF MEDICAL CHILD SUPPORT ORDERS
NYU Hospitals Center (the “Administrator”) will follow these procedures in determining whether a medical child
support order is a qualified medical child support order (a “QMCSO”) , within the meaning of section 609(a) (A) of
ERISA.
1. Plans Covered: These procedures apply to the NYU Hospitals Center Health & Welfare Plan (plan no. 507 )
2. Notice of Receipt: When a medical child support order is received, the Administrator will notify you of their receipt of the order and will provide a copy of these procedures to you and each “alternate recipient” covered under the order .
For the purposes of these procedures, the term “alternate recipient” means any child of a participant who
is recognized by the medical child support order as having a right to enrollment under a group health
plan with respect to such participant.
3. Addresses: All notices and other correspondence to the Administrator about the order shall be addressed to :
Plan Administrator
c/o NYULMC Benefit Services Department,
NYU Hospitals Center
One Park Avenue, 16th Floor, New York, NY 10016
The Administrator will send all notices or other correspondence about the order to you or alternate recipient at the
addresses indicated in the order. An alternate recipient may designate, in writing, a representative to receive copies
of notices that are sent to the alternate recipient with respect to a medical child support order.
4.
Determination and Notification by Administrator: The Administrator will determine whether the medical
child support order is a qualified order, and notify the participant and each alternate recipient of its determination.
The Administrator will make the determination and notification under this Paragraph 4 within a reasonable
period of time after the medical child support order is received. The period of time for determination and
notification may vary depending on whether the Administrator consults with counsel as the Administrator
deems necessary or appropriate.
A medical child support order will not be considered a qualified order if it requires the plan(s) to provide any type or
form of benefit, or any option, not otherwise provided under the plans - except to the extent necessary to meet the requirements of a law relating to medical .
5. Effect of Determination: If the order is determined to be a Qualified Medical Child Support Order (QMCSO)
by the Administrator, the following provisions will be effective, to the extent enforced by the QMCSO:
a) The Administrator will enroll each alternate recipient in the plan(s) designated in the QMCSO (if not already
enrolled) not withstanding the participant’s failure to sign an enrollment application or a similar form(s);
provided that the alternate recipient’s custodial parent applies for enrollment and that the participant is
eligible for such coverage under the applicable plan(s).
Enrollment of an alternate recipient will occur without regard to any open enrollment or annual election
period restrictions that would otherwise apply under the plan(s), and will be effective as of the first day of the
month coincident with or next following the date the Administrator receives the enrollment application (which in no event
shall be earlier than the date medical child support order is deemed qualified by the Administrator).
b) Each alternate recipient’s enrollment in the plan or plan(s) by the Administrator pursuant to a QMCSO will
not be denied on the grounds that the alternate recipient : (1) was born out of wedlock, (ii) is not claimed
as a dependent on the participant’s federal income tax return, or (iii) does not reside with the participant or
within the service area of the plan or plans.
c) NYUHC will withhold each pay period from the participant’s compensation the participant’s share of the
cost of coverage (if any) for each alternate recipient under the plan(s); provided however, that the amount
withheld does not exceed the maximum amount permitted to be withheld under 15 U.S.C. §1673(b) (§303(b)
of the Consumer Credit Protection Act).
6. Administration of Benefits:
a) An alternate recipient under a QMCSO will be considered a beneficiary under the plan(s) for purposes of
ERISA.
b) An alternate recipient under any medical child support order shall be considered a participant under the
plan(s) for purposes of reporting and disclosure requirements of Title I, part 1 of ERISA.
c) An alternate recipient’s eligibility for, or receipt of, Medicaid benefits will not be taken into account in
enrolling them in the plan(s), or in the determination or payment of benefits for the alternate recipient
under the plan(s).
d) Any payment for benefits made by a plan(s) according to a medical child support order in reimbursement
for expenses paid by an alternate recipient or an alternate recipient’s custodial parent or legal guardian shall
be made to the alternate recipient or the alternate recipient’s custodial parent or legal guardian.
e) In the event the participant is not the custodial parent of the alternate recipient, the Administrator will, to
the extent enforced by a QMCSO, (i) provide information to the custodial parent as may be necessary for
the alternate recipient to obtain benefits through the plan(s), (ii) permit the custodial parent (or provider,
with the custodial parent’s approval) to submit claims for covered services under the plan(s) without the
approval of the participant, and (ii) to make payment on claims submitted in accordance with clause (ii)
directly to the custodial parent or a state agency administering Medicaid.
f) To the extent enforced by a QMCSO, the Administrator will not disenroll (or eliminate the coverage of)
any alternate recipient unless (i) satisfactory written evidence is provided indicating that the QMCSO is
no longer in effect, or (ii) the alternate recipient is or will be enrolled in comparable health coverage
which will take effect no later that the effective date of the disenrollment , or (iii) NYUHC has eliminated
family health coverage for all its employees (or, if different, all the employees of the affiliated employer of
NYUHC that employs the participant).
g) In the event that the alternate recipient is disenrolled from the plan(s) on account of the participant’s
death or termination with NYUHC (or, if different, the affiliated employer that employed the partici pant), the alternate recipient will be offered COBRA continuation coverage to the extent required by
law.
7. Review of Determination: The participant or an alternate recipient may file a claim with the Administra tor for a review of the Administrator’s determination under Paragraph 4 in accordance with the Plan’s
general procedures for the filing and review of claims. To the fullest extent permitted by law, the Administrator has the discretion to determine all matters relating to the interpretation and operation of these procedures, and the discretion to determine all matters relating to eligibility, coverage and benefits under the
plans. Any determination by the Administrator is final and binding, in the absence of clear and convincing
evidence that the Administrator acted arbitrarily and capriciously.
8. Amendment of Procedures: The Administrator has discretion to amend these procedures at any time as it
deems necessary or appropriate.
9. Governing Law: These procedures will be governed by and construed in accordance with section 609(a)
of ERISA and the laws of the State of New York to the extent not preempted by ERISA or any other federal
statutes or regulations.
THE MEDICAL PLAN OPTIONS
The following medical plan options are available to eligible NYUHC employees under the BeneFlex
and BasicCare programs:
United Healthcare Preferred Provider Organization (PPO)*- Basic
United Healthcare Preferred Provider Organization (PPO)*- Plus
Oxford Exclusive Provider Organization (EPO)**
Empire (HMO) Health Maintenance Organization**
Decline coverage***
* The PPO medical plans offer two ways to access benefits : (1) In-Network and (2) Out-of-Network.
** These plans offer In-Network benefits only
*** This option is available if covered under another medical plan; proof of other medical coverage is required
What is a PPO Plan ?
A Preferred Provider Organization (PPO) is a network of doctors, hospitals and facilities that have agreed to give care
to plan participants at discounted pre-negotiated rates.
Under a PPO plan, you are not required to select a primary care physician and can go directly to a specialist - without a referral from
a Primary Care Physician (PCP).
Of course you can still ask your physician for advice and assistance in coordinating treatment with specialists- it’s up to you.
What is the difference between the HMO and the EPO Plan ?
What the Health Maintenance Organization (HMO and the Exclusive Provider Organization (EPO) have in common is that
they offer medical care through a network of participating doctors, hospitals and other healthcare providers and provide specified
health care services at a fixed cost.
However, under the HMO plan, you are required to select a Primary Care Physician (PCP) to handle your routine medical
needs. The PCP will act as a “gatekeeper” as you are not authorized to see a specialist unless your PCP approves or requests the
consultation with the specialist. Under the EPO Plan, although it is required that you obtain care from providers that participate in
the EPO’s network, you are not required to select a Primary Care Physician to coordinate your care or refer you to specialists.
THE PRESCRIPTION DRUG PLAN OPTIONS
The prescription drug plan is administered by CVS/Caremark, a nationwide provider. The prescription
drug plan options allow eligible plan participants to easily fill prescriptions with participating pharmacies
including the NYU Hospitals Center Pharmacy, where eligible plan participants receive greater savings
when filling prescription medications. The following options are available to eligible employees under
the BeneFlex and BasicCare programs:
Basic Rx Option
Enhanced Rx Option*
*This option is only available to those covered under the BeneFlex program
Eligible employees who enroll in a medical plan (PPO, HMO, or EPO) are automatically enrolled in the Basic Rx Option for Prescription Drug Plan coverage.
Under the BeneFlex and BasicCare programs, the level of prescription drug coverage is tied to your medical coverage
election. Therefore, your coverage level (i.e employee only, employee + 1, or employee + 2 or more) for prescription drug coverage will be the same as that of your medical plan election. In addition, only eligible dependents enrolled under your
medical plan will be covered for prescription drug plan coverage.
If you waive medical coverage, prescription drug coverage is not available to you.
IMPORTANT CONSIDERATIONS WHEN SELECTING A MEDICAL PLAN
Because the BeneFlex and BasicCare programs offer a variety of medical plan options, careful consideration of your
individual health care needs and those of your family members is essential to selecting the right plan and making those
benefits work for you and your family. The following highlight important features of the PPO, EPO, and HMO medical plans that you should consider before making a final decision.
Accessing Medical Care Under The UnitedHealthcare (UHC) PPO Plans
Both UnitedHealthcare PPO Basic and Plus plans provide eligible participants with the freedom to determine how they
want to access care. Both Medical care can be accessed through “in-network providers” or “out-of-network network
providers” and you make this decision at the “point of service” (i.e each time you access medical care).
Both UHC PPO plan options share the same network of providers and provide coverage for the same eligible
services. The only difference is that your annual contributions (withheld on a pre-tax basis each paycheck) for coverage under the PPO Plus plan are higher because the PPO Plan pays a higher level of benefits for eligible services. As a
result, you incur lower out-of-pocket expenses when you access medical care under the PPO Plus plan option (to compare out-of-pocket expenses under the PPO plans, refer to the Benefit Summaries for the UHC PPO Basic
and Plus plan options in this Summary Plan Description).
Another important aspect of the PPO plans to consider is they also provide for added flexibility in access to medical
care because plan participants are not required to select a “Primary Care Physician (PCP)” to coordinate their medical care. This eliminates the need of obtaining “PCP referrals” before consulting with a specialist regarding a medical
condition. Although not required under the PPO plans, selecting a Primary Care Physician always remains an available
option, should you wish to receive assistance in managing your medical care or course of treatment. Whether enrolled
under the UnitedHealthcare PPO Basic or Plus Plan, eligible employees and dependents can access medical
care from the following types of health care providers:
In-Network Providers (2 types)
“In-Network” providers are the plan’s network of doctors, hospitals, and other health care facilities who have negotiated discounted fees with UnitedHealthcare and, in turn, those discounts are passed on to plan participants. Under the
UnitedHealthcare PPO Basic and Plus options, you have the option to access medical care from the following “innetwork” providers:
(1) “Top Tier” In-Network Providers
“Top Tier Providers” include NYU Hospitals Center and NYU Hospital for Joint Diseases (HJD), and
NYUHC & HJD Physicians that participate in the UnitedHealthcare provider network, and in addition,
have also have agreed to be “Top Tier” providers for NYULMC plan participants . This means when you
receive medical care from participating providers of NYULMC and HJD who are participants in the Top
Tier network, you receive the greatest level of benefits coverage available under the plan at the least
out-of-pocket cost.
(2) “Middle Tier” In-Network Providers
“Middle Tier” providers are providers who participate in the UnitedHealthcare PPO General Network.
When you receive care from Middle Tier providers, you receive a high level of benefits and incur
moderate out-of-pocket expenses for eligible services when you seek care from other participating
providers in the UnitedHealthcare PPO General Network.
Out-of Network Providers
When you obtain medical care from “out-of-network” providers– which include any health care provider outside of
the plan’s network, you receive the lowest level of benefits and incur the greatest out-of-pocket expense. This is
because out-of-network providers do not participate in the UnitedHealthcare Provider Network and therefore these
providers have no contractual commitment to offer discounted fees to plan participants.
TYPES OF BENEFIT PAYMENTS & COSTS UNDER THE PPO PLANS
“Allowable Charges” For In-Network Services
As stated in the previous section, under the UnitedHealthcare PPO Plans, you receive greater benefits when you access
care from “in-network” providers because they are contracted to charge negotiated discounted rates to plan participants. In addition, when you receive in-network provider services under the PPO plans, you are not responsible for
charges in excess of the discounted rates that your provider has contracted to accept as payment for eligible innetwork services you receive. Therefore, when you receive in-network provider services, you are only responsible for
the “allowable charges” or “allowable rates” for the service(s) you receive (up to the in-network deductible for your
PPO plan).
The “allowable rate” for an eligible in-network service refers to the maximum that an in-network provider is
allowed to charge you for eligible service(s) received.
In-Network Benefit Payments & Costs
Co-payments
When you access in-network care from either NYUHC/HJD (“Top Tier”) in-network providers or UnitedHealthcare
General Network (“Middle Tier”) providers for an office visit, you may be responsible for a “co-payment”, which is
a flat dollar amount you pay as your share of the cost for certain health services and supplies. Co-payments
apply to certain in-network services only; and do not apply to out-of-network services (except for out-of-network hospitalizations where a hospital admission copayment would be required).
In-Network Annual Deductible
When you receive care from UnitedHealthcare General Network (“Middle Tier”) providers for services provided that
are billed beyond an office visit, each year you will be required to pay a portion of covered expenses before the plan
begins to pay benefits. This is referred to as the “in-network annual deductible”.
Please note that in-network annual deductible only applies to eligible “Middle Tier” provider services
You are NOT responsible for satisfying a deductible when you receive eligible services from participating
NYUHC/HJD (“Top Tier”) in-network providers.
If you are covering a dependent, both you and your covered dependent must each satisfy the in-network annual deductible before the Plan begins to pay for your individual Middle Tier in– network provider services. If you are covering two or more dependents, expenses related to you and your covered dependents are combined to satisfy
your in-network “Family” deductible.
In-Network Co-insurance
After you have satisfied your in-network annual deductible, an “in-network coinsurance” will apply to eligible services
when using Top Tier or Middle Tier in-network providers. Your in-network co-insurance is a percentage of covered
charges based on the allowable amounts under the Plan. You pay towards your eligible expenses for the in-network
services you receive and cannot be “balance billed” (i.e billed for charges in excess of the allowable rates for services
received) by your in-network provider.
In-Network Out-of-Pocket Maximum
The “in-network out-of-pocket maximum” refers to the maximum amount you would be required to pay toward
eligible expenses before the plan pays 100% of your eligible expenses for the remainder of the calendar year.
Please note that your Middle Tier annual in-network deductible, copayments as well as coinsurance
incurred for eligible in-network services received, will ALL count towards reaching the “in-network out-ofpocket maximum” according to your plan.
OUT-OF-NETWORK BENEFIT PAYMENTS & COSTS
“Allowable Charges” For Out-of-Network Services
Each time you receive out-of-network provider services, the plan will cover a portion of eligible charges based on the
“allowable rate(s)” for the out-of-network services received. When you receive care from an out-of-network provider, UnitedHealthcare determines the allowable rate for the eligible service received based on ‘110% of the Medicare
Rate’ for that service .
The allowable charges for your out-of-network provider services are first applied to your “annual out-of-network
deductible” until the deductible is satisfied. Once the out-of-network deductible is satisfied, the Plan begins to pay
benefits for any eligible out-of-network service you receive going forward based on your plan’s “out-of-network coinsurance level” (refer to the following section for more details).
Out-of-Network Annual Deductible
When obtaining medical care from “out-of-network” providers, each year you will be required to pay a portion of covered expenses before the plan begins to pay benefits. This is referred to as the “out-of-network annual deductible”.
If you are covering a dependent, both you and your covered dependent must each satisfy the out-of-network annual
deductible before the Plan begins to pay for your individual out-of-network provider services. If you are covering two
or more dependents, expenses related to you and your covered dependents are combined to satisfy your out-of-network
“Family” deductible.
Please be advised that the annual deductibles for in-network and out-of-network are separate. As a result, eligible expenses for in-network provider services do not apply towards satisfying the “out-of-network deductible” and vice versa.
Out-of-Network Coinsurance
After you have satisfied your out-of-network annual deductible, “out-of-network co-insurance” will apply to eligible
out-of-network provider services. Your out-of-network co-insurance is a percentage of covered charges that you pay
towards your eligible expenses based on the allowable rate (which is 110% of the Medicare) for the out-of-network
services received.
Out-of-Network Out-of-Pocket Maximum
The “Out-of-Network Out-of-Pocket Maximum” refers to the maximum amount you would pay toward eligible
out-of-network expenses (based on allowable charges) before the plan pays 100% of the allowable eligible out-ofnetwork expenses for the remainder of the calendar year.
You are responsible for any amounts exceeding the allowable charges for out-of-network services
received (up to the billed charges submitted by the out-of-network provider) .
When considering coverage under the UnitedHealthcare PPO plans, it is important to keep in mind that the percentage
of the costs that the Plan pays for eligible services you receive, your ‘out-of-pocket’ expenses for the eligible services
you receive as well as your share of the cost for your coverage under the Plan, mainly depend on the following factors:
The PPO plan you select
(i.e PPO Basic Plan vs. PPO Plus Plan)
The type of providers utilized each time you access care
(i.e Top Tier, Middle Tier or Out-of-Network providers)
Another important aspect of the PPO plans to keep in mind is that benefits paid for eligible services you receive under
the Plan are based on the participation status of the provider you utilize (i.e Top Tier, Middle Tier, or Out-of-Network
provider). This includes ancillary services provided during a hospital stay - such services are covered based on the
network participation of the hospital.
For more detailed information on the PPO plans, refer to section titled ‘The UnitedHealthcare Preferred
Provider Organization (PPO) Plans’ .
ACCESSING MEDICAL CARE UNDER AN EPO OR HMO PLAN
Unlike the PPO plans, the EPO and HMO plans provide “in-network benefits” only. Services received outside
their respective provider networks (out-of-network) are not covered, except in an emergency. This means if you
seek care with an ‘out-of-network provider’ , those services will not be covered, and you will be responsible for the
full amount of the incurred expense for those services.
If you select the HMO plan , you are required to select a Primary Care Physician (PCP) for yourself to coordinate all of your health care needs. In addition each eligible dependent that you elect to cover under the
HMO plan must also designate a PCP. Each time you need care, you must go through your PCP to receive benefits
under the HMO plan. If you are electing HMO coverage for the first time (or a different HMO than you are currently enrolled in), or you are adding a dependent not previously covered, you will need to select a PCP for each
family member .
The selection of a Primary care Physician is not required under the EPO plan .
Benefit Payments & Costs Under an EPO or HMO Plan
Most services obtained in-network are covered at 100% after a co-payment and generally hospitalization is covered
at 100%. For more information , refer to section dedicated to ‘ The Exclusive Provider Organization (EPO)
and Health Maintenance Organization (HMO)’.
WHEN DECIDING ON A MEDICAL PLAN – ASK YOURSELF…
•
Do I need coverage for myself only or do I also need to cover any eligible family members?
•
How much money am I willing to pay out of my own pocket for medical care ?
•
How often will my family and I be using medical services this year?
•
How much freedom do I need in accessing care?
•
Can I afford to choose an option with a higher out-of-pocket maximum and deductible?
•
Do I have access to other medical coverage — for example, through my spouse’s employer?
IMPORTANT CONSIDERATIONS REGARDING PRESCRIPTION DRUG BENEFITS
As mentioned previously, if you enroll in a medical plan– either a PPO, EPO or HMO plan – you are automatically
enrolled in the CVS/Caremark-Basic Rx Plan. Employees who are eligible for medical coverage under the BeneFlex
program can elect additional prescription drug coverage by purchasing the CVS/Caremark - Enhanced Rx Plan option .
Prescription drug coverage is based on CVS/Caremark’s ‘Preferred Drug List’ which is a list of preferred
“FDA approved” prescription drug medications that CVS/Caremark elects to cover because of their quality and costeffectiveness.
The benefits you receive for prescription drug coverage under the Basic or Enhanced Rx option is determined by the
plan option and where you have your prescription(s) filled (participating pharmacy or mail service pharmacy). The prescription drug plans are also based on a “three-tier” copayment structure which determines your share of the cost for
your prescription drug medication(s) according to whether the drug is considered by CVS/Caremark to be ‘Generic’,
‘Preferred’, or ‘Non-Preferred’.
For more detailed information , refer to section on ‘The Prescription Drug Plan’ in this booklet.
PRESCRIPTION DRUG COVERAGE– ASK YOURSELF….
Are your prescription drug medications listed under the CVS/Caremark Preferred Drug List?
Are your prescription medications typically generic, or brand-name drugs?
If your doctor typically prescribes brand-name medications for you or if your medications are not covered
under the CVS/Caremark Preferred Drug List, find out from your doctor if your prescription(s) can be
changed to a comparable generic medication or a medication that is on the Preferred Drug List .
Are you taking long term medications ?
If any of your prescribed medications are taken for long term or chronic conditions (i.e hypertension, diabetes, etc..) you can save money by receiving a 90-day supply via the CVS/Caremark Mail Service Pharmacy, at CVS/Pharmacy stores , and NYUHC Pharmacy.
ENROLLMENT FOR MEDICAL AND PRESCRIPTION DRUG
COVERAGE
Coverage Eligibility Date
Newly eligible employees are given the opportunity to enroll for coverage as of their “Eligibility Date”. Provided it
is the first of the month, your eligibility date will either be your first official date of work or the date of a change to an
eligible status or job classification. If your first official date of work or change in status or job classification is after the
first of the month, then your eligibility date for benefits will be the first of the following month.
Medical and Prescription drug plan coverage under both the BeneFlex and BasicCare programs begins on your
“Eligibility Date”. However, please note that benefits will not be paid for any medical expenses that you may
have incurred prior to your eligibility date under the medical and prescription drug plans offered by NYUHC.
Enrollment Period
You MUST enroll for medical and prescription drug coverage by 30 days from your “eligibility date”. If you do not
enroll for coverage within 30 days of your eligibility date, you will be provided with ‘Default’ medical and prescription
drug plan coverage (refer to the section on ‘Declining Coverage vs. Defaulting to Limited Coverage’ for more
details) .
The benefits enrollment process is web-based and you will need to access our Benefits Enrollment website in order to
select coverage during your 30-day enrollment period for you and your eligible dependents which include your spouse
or registered domestic partner, your child(ren) and/or your registered domestic partner’s children. Part of the online
benefits enrollment process requires that you certify your dependents’ eligibility for coverage under the NYUHC health
plans based on the definition of eligible dependents defined in this Summary Plan Description. You are required to
complete the online dependent certification step for each dependent whether or not you decide to enroll them for coverage. You will not be permitted to proceed with your online benefit enrollment unless you complete the dependent
certification step for your dependents.
Once you have submitted and finalized your benefit elections for you and/or eligible dependents you will need review
and print out a copy of your ‘Confirmation Statement’ summarizing your benefit elections. You are expected to review the statement for accuracy. If you make any final changes or corrections to your benefit elections on the Benefits
Enrollment site during your 30-day enrollment period you will need to print another copy of your Benefits Confirmation Statement reflecting your changes.
It is important to note that once you enroll for benefits, you will not be able to make any changes to your benefits until
the next Annual Open Enrollment Period unless you experience a “qualifying event”. A ‘qualifying event’ is a
work status change or family event defined by the IRS that would permit changes to your current benefit. For further
details , please refer to the section on ‘Changing Coverage During The Year’ .
About Annual Open Enrollment Periods
An ‘Annual Open Enrollment Period’ is designated every year by NYUHC for eligible employees. During this period, all eligible employees and their eligible dependents can enroll for coverage, decline coverage or change benefit
elections. The Annual Open Enrollment period is determined at the discretion of NYUHC, but is generally held before the start of each Plan Year (i.e before January 1st of any given year).
Each year during the Annual Open Enrollment Period you will also be expected to certify your dependents’
eligibility for coverage under the NYUHC health plans for the following Plan Year online via the Benefits Enrollment site.
As stated in the section above, eligible employees generally cannot make changes to their benefits during the plan year,
unless they experience a ‘qualifying event’.
PROVIDING MEDICAL AND PRESCRIPTION DRUG COVERAGE
FOR DEPENDENTS
Enrolling Eligible Dependents
As mentioned in the prior section, part of the online benefits enrollment process requires that you certify your dependents’ eligibility for coverage under the NYUHC health plans based on the definition of eligible dependents defined in
this Summary Plan Description. You are required to complete the online dependent certification step for each dependent whether or not you decide to enroll them for coverage. You will not be permitted to proceed with your online
benefit enrollment unless you complete the dependent certification step for your dependents.
Another mandatory condition for providing dependent coverage is that eligible employees must enroll for medical and
prescription drug plan coverage in order to provide coverage for eligible dependents. Therefore, if you do not enroll
for medical and prescription drug coverage, you will NOT be permitted to provide coverage to your eligible dependents.
Dependents who are eligible for coverage can be enrolled on the date the Employee first becomes eligible for coverage
or may be added or removed during an Annual Open Enrollment period or due to a qualifying event.
Coverage Eligibility Dates For Dependents
The initial eligibility period for dependents is also 30 days from the date that either the employee or dependent is first
eligible for medical and prescription drug coverage. As is the case with employees, dependents who are not enrolled
when they are first eligible for coverage, must wait until the next Annual Open Enrollment Period to enroll for coverage, unless they experience a ‘qualifying event’ (defined by the IRS) during the year that makes them eligible for coverage.
Required Documentation for Enrolled Dependents
If you elect to cover any of your eligible dependents under your medical and prescription drug plan option, you will
need to provide documentation indicating proof of your relationship to each eligible dependent you are covering under
your medical and prescription drug plan option. Acceptable documentation (based on relationship) includes a copy of
the marriage certificate for a spouse, birth certificate for child, or legal adoption or legal guardianship papers for child,
or a completed and approved ‘Statement Domestic Partner Affidavit’ if you are in a domestic partner relationship.
Documentation for enrolled dependents must be submitted to the NYULMC Benefit Services Department no later
than the end of your enrollment period. Failure to provide the required documentation by the deadline will result in
loss of coverage (including retroactive termination of coverage if prior notification was made to the insurance carriers).
In addition, you will not be provided with an opportunity to re-enroll any dependent until the next Open Enrollment
Period, or until you experience a qualifying event that allows for changes to your benefits during the plan year.
Important Note:
Please be advised that if you have certified a dependent as eligible for coverage and they no longer meet that requirement subsequent to their enrollment for coverage you are required to notify the Benefits Services Office within 31 days
of the event so that coverage can be stopped, payroll contribution amounts adjusted and so that notification of rights to
continuation of coverage under the federal COBRA regulations can be issued. In addition, if you certify a spouse, registered domestic partner or child as eligible, and they are subsequently found ineligible, your employment with NYUHC
may be terminated. In addition, the continuation of benefits under federal COBRA regulation will not be extended, and
eligibility for future retiree medical benefits will be rescinded.
New York State Young Adult Law—Impact on Coverage for Dependent Children
Signed into law by Governor Patterson on 7/29/2009 (with an effective date of January 1, 2010 for our plans), the Young
Adult legislation requires NY State health plan insurers to offer parents optional coverage for unmarried children up to the
age of 29; regardless of financial dependence. However, keep in mind that under NYS Young Adult Law, coverage
cannot be provided to the young adult’s children .
How Young Adult Law Affects Our Medical Plans
This legislation applies ONLY to fully-insured medical plans (i.e our Empire HMO plan). The legislation
does not apply to self-funded/self-insured plans, due to federal preemption under the Employee Retirement Income
Security Act (ERISA); which applies to our PPO, Prescription, Dental, and Vision plans. Because our medical plans
allow for dependent children to be covered until the end of the month in which the 26th birthday occurs, the NYS
Young Adult Law will impact those dependent children who fall outside of this category up to the age of 29.
Employees who wish to have their Adult child enrolled for coverage must:
▪ Be eligible for and enrolled under the Empire HMO plan .
▪ Have an adult child that is not be eligible for employer sponsored health insurance or covered by Medicare
▪ Have an adult child who lives, works, or resides in NY State
▪ Make written request during the plan’s annual open enrollment, or
▪ Make written request within 60 days of the adult child terminating coverage due to reaching the age limit
for the plan (end of the month in which age 26 is reached).
The following are instances when coverage for your Young Adult child can be requested:
During an Annual 30-Day Open Enrollment Period for coverage for an upcoming year.
Within 60 days of the date that coverage would otherwise end under our policy due to reaching
the maximum age for dependent coverage (for our plans this would be to the end of the month in which
the 26th birthday occurs).
Within 60 days of newly meeting the NYS Law requirements for Young Adult Coverage
(for example, if young adult moved back to New York State after living outside the state).
If the aforementioned criteria is satisfied and you wish to enroll your child under the Young Adult law, you must contact the NYULMC Benefits Services department (in writing or in person). Once contacted, you will be instructed to
complete and submit a ‘Young Adult Coverage Enrollment Form’ (with required documentation) in order for
your election to be processed. It’s also important to note that although you be enrolled in the Empire HMO in order
to provide coverage for your adult child under the Young Adult Law, your adult child will not be enrolled or set up as
a “dependent” under your medical coverage. Rather the Young Adult law stipulates that the adult child will be set up
and enrolled under the same plan selected by you, the employee, but under enrolled under a separate contract (with
NO prescription drug coverage).
Furthermore, coverage under the NYS Young Adult Law for the adult child will be charged at ‘full group rate’.
Employer contributions are not made for Adult child coverage– the employee pays the full cost via payroll deductions . Premiums for Young Adult coverage will be deducted on a pre-tax basis for the balance of the current year in
which your adult child attained age 26. Thereafter, beginning January 1st of the following calendar year, premiums for
the young adult coverage will be deducted on a post-tax basis. Contact the NYULMC Benefits Services Department
FINAL REMINDERS WHEN ENROLLING FOR COVERAGE
If you are a new hire or otherwise newly eligible to enroll in benefits under either the BeneFlex or Basic
Care program, and you do not enroll by the last day of the enrollment period, you will be assigned
‘limited coverage’ that may not meet your needs or those of your eligible dependents (for more in
formation, see section on ‘Declining Coverage vs. Defaulting to Limited Coverage’ .)
Be sure to consider your plan options carefully before making your final elections. You cannot change your
benefit elections during the year unless you experience a ‘qualifying event’ (see section on ‘Changing Coverage
During the Year’ .
▪
Be sure to submit any required supporting documentation to complete your enrollment (i.e marriage certificate, birth certificates for dependent children, domestic partner affidavits , etc..)
CHANGING COVERAGE DURING THE YEAR
Based on current IRS regulations, once you elect medical coverage, you cannot make any changes during the plan year
(January 1st through December 31st). The ONLY exception to this rule is when you have a ‘Qualifying Event’
(meaning a qualified change in work or family status as defined by the IRS).
In accordance with government regulations, insured and self-insured group health plans (i.e such as The NYUHC
Health & Welfare Plan) must allow employees who lose other health coverage or acquire certain new dependents to
enroll in the plan within 31 days of the ‘qualifying event’ (without having to wait for the plan’s next open enrollment
period). This mandatory 31-day period is referred to as a ‘Special Enrollment Period’.
Because few circumstances are categorized as qualifying events that would allow for a special enrollment period, it is
important to consider your benefit plan options carefully before making your elections for the year.
Qualifying Events include the following:
Marriage
Gain or loss of a domestic partner
Birth* or adoption of a child
Legal separation or divorce
Changes in your health coverage (or your dependents’ coverage) due to your spouse’s or
Domestic Partner’s change in employment status.
Death of a dependent
Changes in student status or reaching the maximum age for dependent child eligibility
Under the NYUHC Health & Welfare Benefit Plan, if you experience any of the above qualifying events, you are permitted to make changes within 31 days of the event(s). Permitted changes may include any of the following:
(1) an increase OR decrease to coverage level consistent with the qualifying event,
(2) electing or waiving coverage for yourself and/or eligible dependents
(contact the NYULMC Benefit Services Department for more details and for instructions on how to initiate the change).
Note: If changes are not made within 31 days of the qualifying event, you must wait until the Annual Open
Enrollment Period in order to initiate any changes to your benefit plan coverage.
In addition, failure to notify the NYULMC Benefits Services Department within 31 days of the qualifying
event will result in the loss of the opportunity to be offered COBRA (the ability to continue coverage based
on eligibility for the active plan by paying the full cost of the benefit explained further in the section on
‘Continuation of Benefits Under COBRA in this booklet).
* Special Provision for Newborn Children
Plan benefits are payable for a newborn child for 31 days after the child’s birth, even if you have not
enrolled the child. However, you are still required to enroll the child within 31 days of birth
in order for coverage to be continued for that child and for coverage to be in effect beyond
the first 31 days.
).
The chart below shows how you may change your benefit plan coverage if you experience a qualifying change in your
family status.
1
QUALIFYING EVENT
MEDICAL AND PRESCRIPTION DRUG COVERAGE
Marriage
Increase/decrease coverage level/decline coverage
Gain/loss of domestic partner
Increase/decrease coverage level/decline coverage
Birth or adoption of a child
(including legal guardianship)
Increase/decrease family coverage level/elect/decline coverage
Legal separation or divorce
Increase/decrease family coverage level/elect coverage
Change in your spouse’s employment
or benefits
Increase/decrease family coverage level/elect/decline coverage
Change in your domestic partner’s
employment or benefits
Increase/decrease family coverage level/elect/decline coverage
Death of a dependent1
Increase/decrease family coverage level/elect coverage
Dependent child reaches age 261
Decrease coverage level
See the definition of an eligible dependent in this booklet.
RULES GOVERNING SPECIAL ENROLLMENT
In accordance with regulations under The Health Insurance Portability and Accountability Act of 1996 (HIPAA),
the NYU Hospitals Center Employee Benefit Plan (“the Plan”) is subject to certain rules with respect to special enrollment in the following instances:
Special Enrollment Under The Plan Due To ‘Loss of Other Coverage’
Eligible employees and dependents who lose other health plan coverage due to qualifying events are entitled to a special
enrollment period- even if they could elect other coverage such as COBRA.
Employees and dependents eligible for coverage under the NYUHC Health & Welfare Plan will be permitted to enroll
if coverage is lost under one of the following three circumstances:
(1) Loss of Eligibility’ Under the Other Group Health Plan
If you and/or your eligible dependent(s) waived coverage under the Plan and your other group health coverage is
terminated due to loss of eligibility, you will be permitted to enroll under the Plan within 31 days of termination of
such coverage. Qualifying events that are commonly associated with loss of eligibility include– losing dependent
status, legal separation, divorce, death, termination of employment, and reduction in the number of hours of
employment.
However, there are other instances that may also result in the loss of other group health coverage due to loss
of eligibility such as the following:
discontinuation of any benefits to the class of similarly situated individuals that includes the employee
and/or eligible dependent (such as termination of group health coverage for part-time employees)
losing coverage because the individual no longer lives or works in that plan’s service area (whether or
not it was the individual’s choice), if the plan does not provide benefits to individuals who do not live
or work in its service area and no other benefit package is available to the individual.
(2) End of Employer Contributions Under the Other Group Health Plan
Employees and/or their eligible dependents will also be permitted to enroll under the NYUHC Employee
Benefit Plan during in cases where the employer sponsoring the other group health plan in which they are
enrolled, stops making contributions toward their benefit coverage.
The employee and/or eligible dependent will be permitted to enroll under the Plan within 31 days of this
qualifying event if the employee or dependent continues the other group health plan coverage by paying the
amount previously paid by the Employer.
(3) End of COBRA Coverage Under the Other Group Health Plan
If COBRA coverage is lost under another group health plan, you and/or your eligible dependent(s) will be
permitted to enroll in the Plan within 31 days of the date your COBRA coverage terminated under the
other group health plan.
Special Enrollment Under The Plan Due To ‘Newly Acquired Dependents’
Special enrollment periods also apply in cases of newly acquired dependents such as marriage, birth or adoption of a
child. Acquiring a new dependent also grants special enrollment rights to a current employee, the employee’s spouse, or
both, even if they previously declined coverage.
For example, in the cases of a birth of a child, eligible employees can add their newborn baby to their existing coverage
under the Plan within 31 days of birth. Furthermore, even if the employee and spouse previously waived coverage
under the Plan, the birth of a newborn child affords the employee and his/her spouse the opportunity to enroll for
coverage under the Plan within 31 days of the child’s birth.
QUALIFYING EVENT ELIGIBILITY DATES FOR ‘SUBSEQUENT DEPENDENTS’
“Subsequent
Dependents” are family members who become eligible dependents after the date the employee first becomes eligible for benefits coverage as a result of a qualifying event.
For Subsequent Dependents, their special enrollment period is the 31-day period which begins with the date
the person becomes a Dependent. In addition, any of your other eligible Dependents may also be enrolled at the
same time, if they are not already covered under the Plan, subject to the same enrollment requirements.
Eligibility dates for subsequent dependents are summarized as follows:
For a spouse or domestic partner: The eligibility date will be the first of the month following the
date of marriage, registration of domestic partnership, or the date the Domestic Partner Affidavit is
approved unless the marriage date, domestic partner registration or domestic partnership approval is
the first of the month.
For a newborn:
The eligibility date will be the actual date of birth.
For an adopted child:
For any other child:
The date of adoption or placement for adoption.
The date the child becomes a Dependent.
CHANGES TO ‘INELIGIBLE’ STATUS
For Covered Employees
If you are in enrolled for medical and prescription drug coverage and you become newly ineligible (for instance, if you
terminate employment or your weekly base hours fall below 17.5), your coverage will cease on the last day of the
month.
In such cases such as termination of employment or reduction in hours affecting your benefits eligibility, you may be
entitled to continue your medical and prescription drug coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Benefits may be continued under COBRA for a maximum of (18) months and
in cases of disability, coverage can be continued under COBRA for a maximum period of (29) months.
For Covered Dependents
If, as a result of a qualifying event, any of your enrolled dependents no longer meet the definition of an eligible dependent under the Plan, you are required to contact the NYULMC Benefit Services Department within 31 days of the qualifying event to initiate your dependent’s status change to an ‘ineligible’ status. In such cases, your ineligible dependent(s) will be effectively removed from your medical and prescription drug plans and would be eligible to continue medical and prescription drug coverage under COBRA for a maximum of (36) months.
Failure to notify Benefit Services of a change in your dependent’s status within the required notification period may result in retroactive termination of your ineligible dependent’s coverage and loss of the right to continue benefits for your newly ineligible dependent(s) under the Consolidated Omnibus Budget Reconciliation
Act of 1985 (COBRA).
For more information on continued coverage under COBRA , please refer to the section of this booklet titled
‘Continuation of Health Coverage Under COBRA’ .
DECLINING COVERAGE VS. DEFAULTING TO LIMITED COVERAGE
Declining Coverage
Eligible employees who have medical coverage through another plan- such as their spouse’s employer- have the option
of waiving medical and prescription drug coverage. BeneFlex and BasicCare eligible employees can elect to waive coverage .
Defaulting to Limited Coverage
If you do not elect to decline coverage within the enrollment deadline (indicated in your Enrollment packet) , you will
be automatically assigned ‘limited coverage’.
Default Limited Medical and Prescription Drug Coverage is outlined below:
Benefit Plan Type
Medical Plan
Prescription Drug
Plan
Default Plan Coverage
Coverage Level
UnitedHealthcare
PPO Basic Plan
CVS/Caremark –
Basic Rx Coverage
Employee Only
Employee Only
Please keep in mind that if you receive the default plan coverage, no coverage will be provided to any of your
eligible dependents, and changes are not allowed until the annual open enrollment period unless you experience a qualifying event as described in the section on ‘Changing Coverage During The Year’ . Furthermore,
you will be required to make any payments for coverage under the ‘Default’ benefits.
THE UNITEDHEALTHCARE (UHC)
PREFERRED PROVIDER ORGANIZATION (PPO) PLANS
The UnitedHealthcare PPO Basic and Plus plans share the same network of providers and generally provide
coverage for the same eligible services with some differences. However employees who elect coverage under the
PPO Plus Plan will be required to pay higher contributions to account for lower out-of-pocket expenses incurred
when utilizing the plan under the PPO Plus option (refer to the Benefit Summaries to compare out-of-pocket expenses
for eligible services under the PPO Basic and PPO Plus Plan).
BENEFIT COVERAGE LEVELS
Under the UnitedHealthcare PPO Basic and Plus plan options, you may access benefits through “in-network” or
“out-of-network” providers. The level of benefits you receive when you access medical care depends on the type of
network provider you select . Outlined below are the features of each type of network provider available under the
UHC PPO plans:
NYULMC/HJD Network (“Top Tier”) Coverage
The “Top Tier” Network is comprised of certain providers of NYU Langone Medical Center (NYULMC) and NYU
Hospital for Joint Diseases (HJD) who have contractually negotiated a discounted fee schedule with UnitedHealthcare
for eligible employees of NYU Hospitals Center, NYU Hospitals Center and NYU Hospital of Joint Diseases .
When utilizing Top Tier providers, you receive the highest level of benefits at the least out-of-pocket expense
under the Plan. A listing of NYULMC/HJD providers who participate in the Top Tier Network can be obtained
from the Human Resources Portal at www.nyuonsitehealth.org .
UnitedHealthcare General Network (“Middle Tier”) Coverage
UnitedHealthcare’s General Network (commonly referred to under our Plan as the “Middle Tier” network or
“commercial network”) is comprised of all other providers who have also contracted discounted fee schedules with
UnitedHealthcare. When you receive care from Middle Tier providers, you receive a high level of benefits at a
moderate cost.
Participating UnitedHealthcare General Network Providers are listed in a separate UnitedHealthcare Provider roster.
Information regarding a provider’s network participation status can be obtained by visiting UnitedHealthcare’s website
at www.myuhc.com or by contacting UnitedHealthcare’s Member Services at 1-866-936-6007.
Out-of-Network Coverage
Unlike in-network providers, “out- of- network” providers are not contracted with UnitedHealthcare to provide discounted fees for medical services. Furthermore, allowable charges for out-of-network services
(i.e the maximum amount you are responsible to pay for eligible out-of-network services) are based on 110% of the
Medicare Rate for the service you received. Medicare Rates for eligible out-of-network services are typically lower
than the “reasonable and customary billed charges” that out-of-network providers would charge.
As a result, medical services received on an ‘out-of-network’ basis will provide the least level of benefits coverage
available under the PPO plans and you will incur the greatest out-of-pocket cost.
TYPES OF PROVIDERS
Outlined below are examples of the types of providers you have access to under the UnitedHealthcare PPO
plans:
Ambulatory Surgical Centers
Chiropractors
Durable Medical Equipment Providers
Home Health Care Providers/Home IV Providers
Hospices/Hospitals
Physical Therapists
Physicians/Podiatrists
Rehabilitation Facilities
Skilled Nursing Facilities
YOUR PAYMENT RESPONSIBILITIES BEFORE BENEFITS ARE PAID
IN-NETWORK PAYMENT RESPONSIBILITIES
In-Network Annual Deductible
Each Plan Year, under the UnitedHealthcare Basic and Plus PPO plans, you and each of your covered dependents
may be responsible for paying a portion of covered expenses before the Plan pays benefits. This is referred to as the
“annual deductible”.
Factors that determine the amount of your annual deductible (if applicable) include:
Your Network Provider
Under the PPO plans, annual deductibles do not apply to services you receive from NYULMC/HJD
“Top Tier” in-network providers. However, an annual “in-network deductible” will be applied to
eligible services obtained through “Middle Tier” network providers, before the plan begins to pay any
benefits. You will be responsible for the “allowable charges” which are based on “negotiated discounted
rates” for the eligible services received. Each time you obtain services from Middle Tier providers, the
allowable charges for services received are applied to your in-network deductible, until your deductible is
satisfied.
Your Level of Coverage
In-network and out-of-network deductible amounts vary depending on your level of coverage under the
Plan (i.e. employee only, employee + one eligible dependent, or employee + two or more dependents).
The higher your level of coverage under the plan, the higher your total deductible amount will be for
your employee + dependent(s) coverage.
If you are covering one or more dependents under your medical plan, expenses related to you and your
covered dependents are combined to satisfy your total family deductible (i.e in-network and/or out-ofnetwork deductible).
Your Plan
In-network and out-of-network deductible amounts also vary depending on the UnitedHealthcare PPO
plan you select– the PPO Basic or PPO Plus option. Remember that although the network and covered
eligible services are the same for both PPO plans, the PPO Plus plan pays a higher level of benefits which
translate to lower deductible amounts, but require higher paycheck contributions .
Copayments
A “copayment” refers to a flat fee paid for certain covered medical services obtained by Top Tier or Middle
Tier in-network providers and must be paid to the in-network provider at the time services are received.
Copayments do not apply towards satisfying the “annual in-network deductible” for Middle Tier provider
services. However, copayments as well as the in-network annual deductible DO apply towards satisfying the
“ annual out-of-pocket maximum”.
Types of Co-payments under the UnitedHealthcare PPO Plans (Top Tier and Middle Tier services) :
Office Visit Co-payments
You are responsible for an Office Visit copayment when you seek care from Top Tier or Middle Tier
physicians. In the case of services provided in the physician’s office, you may be responsible for other
services provided to you in that office in addition to the co-payment for your regular doctor’s office visit
(i.e if your physician bills separately for these charges). Office co-payments apply to the billed office visit
charge given in connection with each office visit and all Covered Services and Supplies given in connection with each office visit.
Note: The Office Visit co-payment does not apply to the prenatal and postnatal office visits to a
Network obstetrician/gynecologist who is primarily responsible for maternity care.
Outpatient Surgery Copayment
The Outpatient Surgery Copayment applies to Network Hospital Services or Network Ambulatory Surgical
Center Services for outpatient surgery. The Outpatient Surgery Copayment applies for each outpatient
surgery admission.
Please note that the Outpatient Surgery Co-payment does not apply to outpatient surgical procedures performed by Top Tier providers.
Emergency Room Copayment
Emergency Room co-payments apply to each Hospital emergency room visit. Emergency Room services
are payable only if it is determined that the services are covered and there is not a less intensive or more
appr opriate place of service, diagnostic, or treatment alternative that could have been used in lieu of emergency room services (refer to the ‘Glossary’ section for Emergency Care definition). The Emergency Room
Co-payment is waived if you are admitted as a Hospital Inpatient.
Urgent Care Center Copayment
The Urgent Care Center copayment ($35) only applies to services given in a UnitedHealthcare General
Network (Middle Tier) walk-in urgent care center. A referral from your Primary Care Physician is not
required.
Hospital Admission Copayment
Inpatient Copayments apply to each hospital admission to a UnitedHealthcare Network Hospital or Network Rehabilitation Facility except NYU Hospitals Center (NYUHC) , NYU Hospital for Joint Diseases
(HJD) or The Rusk Institute for Rehabilitative Medicine (RIRM).
The Hospital Admission Copayment applies to inpatient Middle Tier and Out-of-Network Hospital services
for each admission, except in the following instances:
A newborn child’s routine Hospital confinement beginning at birth, during the mother’s covered stay
If readmitted to the same hospital (in - or out-of-network) within 90 days of initial admission for
same diagnosis
In-Network Coinsurance
“Coinsurance” refers to a percentage of a covered eligible expense that the Plan pays and you are responsible to pay
the remaining percentage. Your coinsurance levels for eligible in-network provider services depend on the PPO plan
you select. In-Network coinsurance levels apply to most eligible services that do not require a copayment (whether
obtained through a Top Tier or Middle Tier provider). However, for services rendered by Middle Tier providers, the
in-network coinsurance applies to certain eligible services only after the annual “in-network deductible” has been satisfied.
In-Network Annual Out-of-Pocket Maximums
In order to help contain your out-of-pocket expenses for in-network services, the PPO plans include a plan year
“Out-of-Pocket Maximum”. The “Out-of-Pocket Maximum” refers to the annual maximum you pay towards eligible
medical expenses (based on the Plan’s allowable amount for the in-network service(s) you receive), before the Plan
reimburses 100% of eligible expenses for the remainder of the calendar year.
Expenses that apply toward reaching your “in-network out-of-pocket maximum” are based on the “allowable
charges” for expenses you have incurred during the calendar year for eligible in-network services. The term
“allowable charges” refers to the maximum amount a provider is allowed to charge for eligible in-network services
based on negotiated discounted rates (for more details, refer to the ‘In- Network Benefits” section under
‘How Network Benefits Are Paid Under the UnitedHealthcare PPO Plans’ in this booklet).
In addition, eligible in-network services are subject to separate “Top Tier” and “Middle Tier” in-network out-ofpocket maximums. However, a coordination exists between the Top Tier and Middle Tier in-network out-of-pocket
maximums. This means that your eligible Top Tier out-of-pocket expenses can be applied towards satisfying the Middle Tier out-of-pocket maximum and vice versa.
Keep in mind that your Middle Tier deductible, co-payments as well as coinsurance incurred for eligible
Top Tier and Middle Tier services received will ALL count towards reaching the ‘in-network out-of-pocket
maximum’ based on your PPO plan.
Please be advised that the amount of your in-network out-of-pocket maximum will depend on:
(1) your provider’s participation status (i.e in-network or out-of-network)
(2) your level of coverage and
(3) the PPO plan you elected (i.e PPO Basic or PPO Plus Plan) .
Understanding When In-Network Charges Apply
The previous section outlined the types of out-of-pocket expenses that apply to eligible services obtained through innetwork providers. However, it is important to note there are certain eligible services under the UnitedHealthcare
PPO plan that are covered at 100%, and therefore would not be subject to the annual in-network deductible or coinsurance. The following are in-network services that are covered at 100% under the PPO plan and are NOT subject to
the in-network annual deductible or coinsurance:
Most services that require a “copayment”: Except hospitalizations, which are subject to a hospital copay
ment, the in-network deductible (Middle Tier provider services only) and coinsurance.
Nursery Care for Newborns: Routine hospital nursery charges for the newborn during the mother’s covered
stay following delivery are covered at 100% under the plan and not subject to separate coinsurance amounts,
deductible (if applicable) or hospital copayment. The mother’s hospital stay would be subject to applicable coinsurance ,
deductible and copayment amounts.
Inpatient Mental Health: In-patient mental health stays are covered at 100% under the Plan and are not
subject to coinsurance or the annual in-network deductible. However, please note that a hospital co-payment
will apply for hospitalizations at participating Middle tier hospitals .
Outpatient Laboratory Services: Covered eligible laboratory services performed by an in-network provider
on an outpatient basis (doctor’s office, outside laboratory or hospital) are covered at 100% of the allowable
rate, and are not subject to a copayment, coinsurance or the annual in-network deductible (middle tier).
Examples of covered lab services include:
⇒ Hematology & Coagulation (i.e blood counts)
⇒ Immunology (i.e, antibodies)
⇒ Microbiology (i.e., cultures)
⇒ Chemistry (i.e., glucose levels)
Preventive Services: In-network services that are considered preventive are not subject to the in-network
deductible (middle tier) or coinsurance. Services designated by the plan as preventive must also meet certain
conditions including frequency, diagnosis coding as preventive, and established timeframes based on the status
of the patient (adult or well child).
Some examples of preventive services and coverage conditions are:
⇒ Physical Exam, once per calendar year
⇒ EKG, Blood Pressure screening, coinciding with physical exam once per calendar year
⇒ Mammogram, (females age 40+), once per calendar year
⇒ Colonoscopy, (adults age 50 & above), once every five years
Note: The List of Preventive Services is provided in this Summary Plan Description on page 63.
Important Final Note Regarding Coverage for Preventive Services
In-Network Coverage
Preventive care services accessed through “in-network providers” are covered at 100% under the
PPO plans and are NOT subject to the “in-network” deductible and co-insurance.
However, please keep in mind that services received from in-network providers that exceed the frequency and
established timeframes indicated on the ‘List of Preventive Services’ AND services that are otherwise considered
‘preventive’, but are coded as ‘diagnostic’ based on results of the service received, will NOT be considered
“preventive” in nature and will NOT be covered at 100% under the plan. As a result, you will incur out-of-pocket
expenses as these services will be subject to the “in-network” deductible and co-insurance .
Out-of-Network Coverage
You will incur out-of-pocket expenses for preventive services performed by “out-of-network” providers as these services
will be subject to the “out-of-network” deductible and coinsurance and are not covered at 100%.
OUT-OF-NETWORK PAYMENT RESPONSIBILITIES
Out-of-Network Annual Deductible
Each Plan Year, under the United Healthcare Basic and Plus PPO plans, you and each of your covered dependents will
be responsible for paying a portion of covered expenses before the Plan pays benefits for your out-of-network provider
services, referred to as the “out-of-network annual deductible”.
For eligible services received out-of-network, you will be responsible for “allowable charges” based on 110% of Medicare’s rate for the eligible out-of-network service up to your “out-of-network deductible” amount, until the out-ofnetwork deductible is satisfied (for more details refer to section on ‘Out-of-Network Benefits’) .
Please note that in-network and out-of-network deductibles must be satisfied independently of each other as
they are treated separately under the Plan. This means that eligible expenses incurred for services received
“in-network” cannot be applied towards satisfying an “out-of-network deductible” and vice versa.
Out-of-Network Coinsurance
For services rendered by “out-of-network providers”, the out-of-network coinsurance applies to eligible outof-network services after the annual “out-of-network deductible” has been satisfied. Your out-of-network
co-insurance level for eligible out-of-network provider services depend on the PPO plan you select.
Once your “out-of-network” deductible is satisfied, the plan pays a “co-insurance” based on “Allowable
Amounts”. Allowable charges apply to out-of-network services and are calculated based on ‘110% of the
Medicare rate for your eligible service’. The plan calculates the allowable rate for the eligible service, and
applies it to your plan’s co-insurance level (for more details refer to the section on ‘Out-of-Network
Benefits’ )
The final outcome is what is reimbursed by the Plan and you pay the remaining balance of the eligible
expense up to 100% of billed charges as your share of the cost.
Out-of-Network Out-of-Pocket Maximum
Before the plan covers 100% of the allowable amount your eligible expenses for out-of-network services
you receive, your expenses for eligible out-of-network services must reach the ‘out-of-network’ out-ofpocket maximum.
The amounts of your out of-pocket maximums under both the PPO Basic and Plus Plans are the same and
will vary only according to level of coverage (Employee Only, Employee +1, etc..)
Expenses that apply towards reaching the “out-of-network out-of-pocket maximum” are based on
‘110% of the Medicare rate’ for eligible out-of-network provider services (refer to the section on ‘Outof-Network Benefits’ for more details).
HOW NETWORK BENEFITS ARE PAID BY THE UNITEDHEALTHCARE
PPO PLANS
The UnitedHealthcare PPO plans pay benefits for medical services you receive according to the “network” status of the
provider you use each time you access care.
As discussed in the prior sections, under the UnitedHealthcare PPO plans, you always have the flexibility to determine
how you want to receive medical services. Eligible medical services can be obtained either through ‘in-network’ providers (Top Tier or Middle Tier) or ‘out-of-network’ providers.
When in-network providers are used for eligible services, you receive greater benefits at the least out-of-pocket expense.
If you access care through out-of-network providers , you receive the lowest level of benefits available under the Plan at
higher out-of-pocket costs.
Upon enrolling in either of the UnitedHealthcare PPO plans, ID cards for you and your covered dependents will be
mailed to your home. It is strongly encouraged that you confirm your provider’s network status (i.e in-network or outof-network provider) before your office visit and to also present your medical ID card each time you visit a provider.
This helps to determine the level of benefits to be paid for services received and thereby facilitating the processing of
your benefits.
IN-NETWORK BENEFITS
Because in-network providers have contracted with UnitedHealthcare to provide services at a negotiated discounted
rate, the Plan pays benefits based on the negotiated “allowable rates” for the eligible in-network provider services
you received.
“Allowable Rates” refer to the maximum amount a participating provider is allowed to charge for eligible in-network
services based on negotiated discounted rates. In-Network Providers cannot bill you for charge in excess of the allowable rates for the eligible services you receive. However, a provider can bill the patient for any amount not covered by
the Plan (see section below on ‘In-Network Provider Charges Not Covered’).
Each time you receive eligible medical services on an in-network basis, UnitedHealthcare determines the “allowable
rate” for the eligible service(s) and applies the allowable expenses first to your annual in-network deductible (if applicable), until the deductible is satisfied.
Once the in-network deductible is satisfied (or if the in-network deductible does not apply), the Plan begins to pay
benefits. Certain eligible in-network services are paid at 100% under the Plan after you pay the required copayment.
Other eligible in-network services are subject to your plan’s in-network coinsurance level—a percentage of which is the
employee’s responsibility.
The Plan pays benefits for In-Network provider services according to the Schedule of Benefits for the UnitedHealthcare PPO plans for the Basic and Plus plan options (refer to the Benefit Summaries for the UnitedHealthcare
Basic and Plus options in this booklet ).
In-Network Charges Not Covered
Because in-network providers (either Top Tier or the Middle Tier ) have contracted to participate in UnitedHealthcare’s Network, a Network Provider is not permitted to charge you or UnitedHealthcare for certain eligible expenses,
except as stated in the Schedule of Benefits for the UnitedHealthcare PPO Basic and Plus Plans. Furthermore a Network Provider cannot bill you in excess of the allowable charges for the eligible services you receive .
However, keep in mind that you will be fully responsible for the payment of services or supplies that are NOT
covered under the Plan (example of services not covered include ‘unproven’ or ‘cosmetic surgery’ performed
by an in-network provider). In such cases the Network Provider will charge you accordingly to pay for expenses which are not covered by the Plan. Remember that charges for services or supplies that are not covered under the Plan will NOT be paid by the Plan.
Out-of-Network Provider Charges Paid At “In-Network Level”
Radiology, anesthesiology, and pathology services are paid at the ‘in-network‘ level provided these
services are rendered in one of the settings listed below:
Inpatient Hospital
Ambulatory Surgical Center
Emergency Care services, provided they meet the definition of an “emergency” under the Plan, are payable
at the ‘in-network’ level, even if services are received from an out-of-network provider.
OUT-OF-NETWORK BENEFITS
Because out-of-network providers are not contracted to provide care at negotiated discounted fees to eligible plan participants, the Plan pays the lowest amount of benefits when services are accessed on an out-of-network basis. Each
time you access care through out-of-network providers, UnitedHealthcare determines the “allowable amounts” for
the eligible service(s) which is calculated based on ‘110% of the Medicare Rate’ for that service.
Reimbursement Levels For Eligible Out-of-Network Medical Expenses
The reasonable and customary charges for your out-of-network provider services are first applied to your annual outof-network deductible, until the deductible is satisfied. Once the out-of-network deductible is satisfied the Plan begins
to pay benefits for any eligible out-of-network service you receive going forward based on your plan’s out-of-network
coinsurance level. Illustrated below is an example of how reimbursement would be calculated for an out-ofnetwork office visit under the PPO Basic Plan. The example below assumes that the employee has already
satisfied the out-of-network deductible under the Plan.
Type of
Billed Allowable Amount Plan Pays Total Amount
Employee’s Responsibility
the Plan will (percentage) Reimbursed
Service
Amount
consider for
by the Plan
reimbursement**
Office Visit
$250
(PPO Basic Plan)
Hospital Surgery $10,000
(PPO Basic Plan)
$111
50%
$55.50
$55.50
$7,700
50%
$3,850.00
Out-of-Network providers may “balance bill” the
member for the entire cost of the services which may
include charges that exceed the “allowable amounts”
eligible for payment under the Plan.
In this example, the member would be charged for:
Hospital Admission Copay of $1000 Required
under the PPO plan for each out-of-network hospital
stay,
AND
The entire cost of the out-of-network hospital
surgery in the amount of $10,000 is comprised of:
Member’s Out-of-Network Coinsurance Amount
of $3,850: This is the member’s share of the cost for
the hospital surgery under the PPO Basic Plan
which is a 50% coinsurance of the allowable charge
($7700) for the surgery.
Plan’s Out-of-Network Coinsurance Amount of
$3,850 (to be reimbursed to member by the Plan)
Amounts NOT covered by the plan in the
amount of $2,300: The member is also responsible
to pay $2,300 reflecting the out-of-network hospital
surgery charges that EXCEED the “allowable
amount” ($7,700) eligible for payment by the Plan
in this example.
** This is the amount available for reimbursement under the Plan. The Plan first applies the allowable amount based on 110% of the Medicare Rate to
the annual out-of-network deductible for this employee. If the annual out-of-network deductible has been met, then the Plan pays benefits on this
amount based on the coinsurance level according to employee’s plan. The remainder is the employee’s out-of-pocket responsibility.
LIFETIME BENEFIT MAXIMUMS (FOR IN-NETWORK & OUT-OF-NETWORK SERVICES)
“Lifetime Benefit Maximums” refer to the total benefits you may receive during your lifetime from a particular plan
for a particular type of service. The UnitedHealthcare PPO Basic and Plus plans have an “unlimited” Lifetime Plan
Benefit Maximum for services received by in-network or out-of-network providers. This means that the Plan does not
impose any limit on the overall amount of benefits a participant receives during their lifetime enrolled in the Plan.
FILING A CLAIM FOR BENEFITS
If you receive in-network coverage for medical services rendered under either of the two UnitedHealthcare PPO plans,
you do not have to file claims to obtain reimbursement for covered expenses. The in-network provider will file the
claim on your behalf for the eligible service(s) received. For certain eligible in-network services that are subject to
coinsurance, you can expect to be billed by your provider for your share of expenses up to the allowable amount for
the service received.
If you receive medical care from an out-of-network provider, you are responsible for filing claims in order to be reimbursed for expenses incurred, as many out-of-network providers require payment be made in full at the time service is
received. If your out-of-network provider does not require payment at the point of service, you can also expect to be
billed by the provider.
Each time a claim is filed for benefits (whether in-network or out-of-network), UnitedHealthcare produces an
Explanation of Benefits (EOB) Statement* for the service(s) received which identifies charges covered under your
plan as well as your share of expenses (if any). The following section on ‘Understanding Your Explanation of
Benefit (EOB) Statements’ illustrates the types of charges that apply to your claims.
Keep in mind that all completed claims submitted to UnitedHealthcare will be reviewed and, if the claims are denied, in
whole or in part, UnitedHealthcare will provide you (or your covered dependent ) with notice of such denial. If you
intend to appeal a denied claim, you will have the rights outlined in the section on ‘Questions & Appeals Regarding
Benefit Determinations in this booklet.
UNDERSTANDING YOUR EXPLANATION OF BENEFIT (EOB) STATEMENTS:
Provided below is a sample EOB Statement that outlines the components of expenses that apply to your claimswhether they are received on an in-network OR out-of-network basis.
SALLY BAKER
ADDRESS
CITY, STATE ZIP
DATE: 06/02/13
ID# : A 222222222
EMPLOYEE: SALLY BAKER
EXPLANATION OF BENEFITS
SERVICE DETAIL
PROVIDER/
SERVICE
PATIENT/RELAT
CLAIM NUMBER
SALLY
EE
111223333
DATE OF
SERVICE
AMOUNT
CHARGED
NOT
COVERED
AMOUNT
ALLOWED
COPAY OR
DEDUCTIBLE
PLAN
COVERS
BENEFIT
AVAILABLE
Dr. Woods
Doctor Office Visit
STATE OF NEW
YORK NY SRCHG
PLAN PAYS
xxx.xx
** PATIENT PAYS
xxx.xx
EXPLANATION KEY
"Amount Charged”: the actual cost of the service received before any discounts or reductions are applied.
"Not Covered": the portion of expenses incurred for the service that are NOT paid by the plan.
"Amount Allowed” : is the amount the Plan will recognize as the maximum that can be charged for the eligible service under
the plan based on negotiated discounted rates .
For In-Network Services: “Amount Allowed” refers to the maximum amount a provider is allowed to charge for eligible
services based on ‘contracted discounted rates’ negotiated with the insurance carrier.
For Out-of-Network Services: “Amount Allowed” refers to charges that our PPO plans use to calculate reimbursement of
eligible services rendered by “out-of-network” providers based on ‘110% of Medicare’s rate’ for eligible service(s).
“Copay or Deductible”: represents the patient’s out-of-pocket responsibility for the service received.
“Plan Covers”: the percentage the plan pays based on the “Amount Allowed” (#3) for that service (for example, the PPO
Plus plan pays 90% for eligible in-network claims).
"Benefit Available": is the payment made to the provider by UHC for the services performed = “Amount Allowed” (#3)
minus -“Copay/ Deductible (#4) times “Plan Covers” (#5)
Note: The ‘Benefit Available’ column only reflects the plan’s coinsurance amounts (where applicable) for eligible services.
Although the patient’s coinsurance amounts are NOT indicated, the patients’ coinsurance amounts for eligible services
received are included in the ’PATIENT PAYS’ total on the EOB [the difference between “Amount Allowed” (#3) and Benefit
Available (#6)].
“Plan Pays”: the total amount the plan pays for the eligible service based on the “Amount Allowed” (#3) for the service .
“State of New York Surcharge”: Certain services (for example, hospitalizations and radiology services provided on an
in-patient or out-patient basis) are subject to a NYS surcharge whether they are provided on an in-network or out-of-network
basis. The NYS surcharge (which is subject to change) is currently 8.95% of the allowable charges. When you have a service that is subject to the surcharge, your “EOB” will list the corresponding surcharge on a separate line, and the Plan will
pay the required portion. You are responsible for a percentage of these charges (the deductible where applicable, and/or
coinsurance amounts) up to the applicable annual out-of-pocket maximum.
"Patient Pays": the total amount the patient would pay for the eligible service which is based on the difference between the
“Amount Allowed” (#3) for the service and the “Benefit Available” (#6) . The “Patient Pays” total includes copays,
amounts applied to the deductible as well as coinsurance amounts.
Sample “In-Network” EOB Statement
For the purposes of this example the employee is enrolled under the PPO Plus Plan she has already satisfied her
“In-Network Deductible” of $200 . All services listed on this EOB were performed by “Middle Tier” providers.
SALLY BAKER
ADDRESS
CITY, STATE ZIP
EXPLANATION OF BENEFITS
SERVICE DETAIL
PATIENT/RELAT
CLAIM NUMBER
SALLY
EE
111223333
PROVIDER/
DATE OF
SERVICE
Dr. KaiserDoctor Office Visit
1/10
125.00
100.50
MEDCO LABS
Laboratory Services
1/14
305.00
118.30
1/211/22
7500.00
4500.00
1/211/22
402.75
ABC HOSPITAL CTR
In Hospital Misc Services
1/211/22
STATE OF NEW YORK
NY SRCHG
1/211/22
ABC HOSPITAL CTR
Room & Board
STATE OF NEW YORK
NY SRCHG
TOTAL
AMOUNT NOT
AMOUNT
CHARGED COVERED ALLOWED
COPAY OR
PLAN
DEDUCTIBLE COVERS
100%
70.50
100%
118.30
90%
3780.00
402.75
90%
362.48
65000.00
22000.00
90%
20490.27
1969.00
1969.00
100%
1969.00
75301.75
29090.55
Summary:
30.00
BENEFIT
AVAILABLE
300.00
26790.55
330.00
PLAN PAYS
** PATIENT PAYS
$
$
26,790.55
2,300.00
Doctor Office Visit: Plan pays 100% of the “Amount Allowed” ($100.50) for Sally’s doctor office visit minus the $30 copay that Sally is responsible
for under the PPO Basic plan. The total amount paid by the plan is $70.50 (reflected in the ‘Benefit Available’ column).
Outpatient Lab Services: The plan pays 100% of the “Amount Allowed” for the lab services ($118.30), therefore Sally does not incur out-of-pocket
expenses for the lab services performed.
Hospital Room & Board: . The total amount charged is $7,500 and the “amount allowed” under the Plan is $4,500 which is reduced by Sally’s hospital
copay ($300) for a final balance of $4,200. The Plan pays 90% of $4,200 for the room & board charges which is reflected in the ‘Benefit Available’
column as $3,780. Sally’s responsibility is 10% coinsurance of the final balance ($4,200) which is $420.00 (which counts towards her in-network
out-of-pocket maximum of $2,500 under the PPO Plus Plan).
NYS Surcharge: The NYS surcharge on the hospital room & board is 8.95% of the allowable charge of $4,500, which in this case is a total of $402.75.
The Plan pays 90% and Sally’s pays her coinsurance amount of $40.27, which is also applied to her out-of-pocket maximum.
Hospital Misc Services and the NYS Surcharge on the Amount Allowed: The amount charged for the miscellaneous hospital services is $65,000
and the amount allowed under the Plan is $22,000. The Plan is responsible for 90% of the amount allowed (22,000) and Sally’s 10% coinsurance
amount is $2,200. However, Sally would exceed her annual out-of-pocket maximum of $2,500 (under the PPO Plus Plan) by paying the entire $2,200;
therefore, she pays $1,509.73, and the Plan would pay the balance of $690.27. The Plan’s total responsibility for the Hospital Miscellaneous charges is
$20,490.27: $19,800.00 (90% of the allowable amount of $22,000) PLUS $690.27 (the remaining balance of Sally’s coinsurance). Also as a result of
Sally having met her maximum out-of-pocket amount, the Plan will subsequently pay 100% of Sally’s eligible in-network expenses incurred for the rest
of the year, including the NYS Surcharge on this claim ($1,969).
Now let’s look at what charges Sally is responsible for and how they are listed:
**Patient Pays: The amount listed here is Sally’s total patient responsibility based on amounts allowed under the Plan and it takes into consideration the
$200 in-network deductible already paid by Sally earlier in the year.
Here’s a breakdown of Sally’s total out-of-pocket responsibility of $2,300 based on the claims paid on this EOB:
Doctor Office Visit ($30) :applies toward the out-of-pocket maximum
Hospital Copay ($300): applies toward the out-of-pocket maximum
Co-insurance for room & board & NYS surcharge of ($420 and $40.27)* : applies towards the out-of-pocket maximum
Co-insurance for hospital misc. charges of ($1,509.73)*: applies towards the out-of-pocket maximum
Co-insurance for NYS surcharge on hospital misc. charges: ($0.00)* : out-of-pocket maximum has been satisfied.
*** Reminder on Eligible Expenses & In-Network Out-of-Pocket Maximums***
Sally’s $200 middle tier deductible, as well as the $2,300 Sally incurred for co-pays and co-insurance apply towards her reaching her in-network
annual out-of-pocket maximum of $2500 for her Middle Tier services under the PPO Plus Plan. Because Sally reached her in-network outof-pocket maximum, the Plan will subsequently pay 100% of Sally’s eligible in-network expenses incurred for the rest of the calendar year.
Sample “Out-of-Network” EOB Statement
For the purposes of this example, Paul (who is enrolled under the PPO Basic Plan), has already satisfied his
“Out-of-Network Deductible” of $1,200 earlier in the year. Important Note: Paul has also incurred out-ofpocket expenses this year for out-of-network coinsurance totaling 2,000 (which counts towards his ‘Out-ofNetwork Out-of-Pocket Maximum’ of $6000).
PAUL SMITH
ADDRESS
CITY, STATE ZIP
IMPORTANT NOTE:
Benefits paid for the Hospitalization charges on this EOB
were paid at the ‘out-of-network level’.
However, if this was an ’EMERGENCY’ hospitalization,
benefits would be paid at the “in-network middle tier” level.
EXPLANATION OF BENEFITS
SERVICE DETAIL
PATIENT/RELAT
PAUL
EE
222778989
PROVIDER/
SERVICE
DATE OF AMOUNT NOT
SERVICE CHARGED COVERED
LAKEWOOD HOSPITAL
Room & Board
1/13
1/14
STATE OF NEW YORK
NY SRCHG
1/131/14
223.75
LAKEWOOD HOSPITAL
In Hospital Misc Services
1/131/14
65000.00
1/131/14
572.80
STATE OF NEW YORK
NY SRCHG
6500.00
72296.55
4000.00
58600.00
62,600.00
AMOUNT
AL-
COPAY OR
DEDUCTI-
PLAN
COV-
BENEFIT
AVAILABLE
2500.00
1000.00
50%
750.00
223.75
50%
111.88
6400.00
50%
572.80
100%
9696.55
Summary:
3261.87
572.80
4696.55
1000.00
PLAN PAYS
** PATIENT PAYS
$ 4696.55
$ 5000.00
Because all of the services processed on this EOB are for out-of-network claims, Paul will be responsible for both:
His co-insurance amounts after the Plan pays benefits based on the amounts allowed for each service, up to the annual out of pocket maximum of $6,000 AND the amounts “Not Covered” by the Plan (the difference between the “Amount Charged” and “Amount Allowed”).
Please note that amounts not covered by the Plan (the total of $62,600 under the ‘Not Covered’ column) do not count toward the annual
out of pocket maximum.
With this in mind, let’s review these amounts on the EOB:
Hospital Room & Board: The total amount charged is $6,500 and the “amount allowed” under the Plan is $2,500 which is reduced by Paul’s hospital
copay ($1000) for a final balance of $1,500. The Plan pays 50% of $1,500 for the room & board charges which is reflected in the ‘Benefit Available’
column as $750.00. Paul’s responsibility is 50% coinsurance of the final balance ($1,500) which is $750.00 (which counts towards his out-ofnetwork out-of-pocket maximum of $6,000 under the PPO Plus Plan)
NYS Surcharge: The NYS surcharge on the hospital room & board are based on the allowable charges, which in this case is a total of $223.75. The
Plan pays 50% and Paul pays his 50% co-insurance amount of 111.88, which is also applied to his out-of-pocket maximum.
Lakewood Hospital Misc Services and the NYS Surcharge on the Amount Allowed: The total charges are $65,000 and the Plan allows $6,400.
The Plan pays $3,200 (50% of the amount allowed) and Paul’s 50% coinsurance amount is $3,200. However, Paul would exceed his annual out-ofpocket maximum of $6,000 by paying the entire $3,200; therefore, he pays $3,138.13, and the balance (61.87) is paid by the Plan. The Plan pays a
total of $3,261.87 which consists of: $3,200 (50% of the $6400 Allowable Amount) PLUS $61.87 (the remaining balance of Paul’s coinsurance for this
service). As a result of Paul having met his maximum out-of-pocket amount, the Plan will subsequently pay 100% of the allowable amounts for eligible
out-of-network coinsurance incurred for the rest of the year, including the NYS Surcharge on this claim ($572.80).
Now let’s look at what charges Paul is responsible for and how they are listed:
“Not Covered”: Paul is responsible for $62,600 (the total amount listed under the “not covered” column), since the Plan does not allow the entire
charges and the out-of-network provider has not agreed to the contracted rates.
**Patient Pays: The amount listed here is Paul’s total patient responsibility based on amounts allowed under the Plan and it takes into consideration
any deductible amounts already paid, and any co-insurance amounts already paid by employee.
Here’s a breakdown of Paul’s responsibility of $5,000 based on the claims paid on this EOB:
Hospital Co-pay of $1,000 (does NOT apply toward the out-of-pocket maximum)
Co-insurance for room & board & NYS surcharge of ($750 and $111.87)* : applies towards the out-of-pocket maximum
Co-insurance for hospital misc. charges of ($3138.13)*: applies towards the out-of-pocket maximum & brings him to the out-of-pocket maximum when added to the $2,000 coinsurance he incurred earlier in the year (see intro at the top of this page)
Co-insurance for NYS surcharge on hospital misc. charges: ($0.00)* : out-of-pocket maximum of $6,000 has been satisfied
*NOTE: Although Paul’s total out-of-pocket responsibility on this EOB is $5,000, only his total coinsurance amounts for eligible out-ofnetwork services count towards his out-of-pocket maximum. The total coinsurance amount Paul pays that counts towards his out-ofnetwork maximum is $4,000 added to the coinsurance amounts of $2,000 paid on earlier claims in the year is equal to his out-of-pocket maximum of $6,000 for the year. Remember that the hospital copay of $1,000 and the $62,600 under the “Not Covered” column are separate
expenses and do NOT count toward his out-of-pocket maximum .
NOTIFICATION FOR CARE COORDINATION UNDER THE PPO PLANS
Advance notification to the insurer (UnitedHealthcare) is required when receiving certain medical services and supplies
to determine whether the services are “Covered Health Services.” Notification to UnitedHealthcare is designed to
encourage an efficient system of care for employees and their covered dependents by identifying and addressing possible unmet covered health care needs. This may include admission counseling, inpatient care advocacy, and certain discharge planning and disease management activities.
However, the activities involved in the notification process are not a substitute for the medical judgment of
your Physician, and the ultimate decision as to what medical care you or your covered dependents actually
receive must be made by you and your Physician. UnitedHealthcare only determines if the listed service or
supply is a Covered Health Service according to the Plan benefits and provisions.
Notification of Care Coordination is initiated when UnitedHealthcare receives notification of an upcoming treatment or
service. The notification process serves as a gateway to the activities involved in the process and a way for the
employee to let UnitedHealthcare know that they are planning to receive specific health care services. You can contact
UnitedHealthcare by calling the phone number listed on your medical ID card. You can expect to receive phone calls
from UnitedHealthcare when certain treatments are involved.
Please be advised that notification does not guarantee that benefits are payable under this Plan. Benefits are
based on:
•
•
•
The Covered Services and Supplies actually performed or given.
The Covered Person’s eligibility under this Plan on the date the Covered Services and Supplies are performed or given.
Co-payments, deductibles, co-insurance, maximum limits and all other terms of this Plan.
PRE-NOTIFICATION PROCEDURES FOR CARE COORDINATION
Outlined below are procedures that require notification in order to receive the appropriate benefit coverage under the
UnitedHealthcare PPO Plans:
For Inpatient Confinements (non-pregnancy related)
If you are scheduled to undergo a medical procedure that requires you to be confined for a period of time at a
hospital, it is required that you notify UnitedHealthcare at least five (5) working days prior to your hospital
admission date, or as soon as reasonably possible. It is possible that an admission date may not have been
set when your confinement was planned. In this case, it is your responsibility to contact UnitedHealthcare again as
soon as your admission date is set.
For Pregnancies
Pregnancy is subject to following notification time periods:
Prenatal Programs: United Healthcare should be notified during the first trimester (12 weeks) of
Pregnancy. This early notification makes it possible for the mother to participate in the prenatal program.
Inpatient Confinement for Delivery of Child: UnitedHealthcare must be notified only if the inpatient
care for the mother or child is expected to continue beyond:
48 hours following a normal vaginal delivery
96 hours following a cesarean section
For inpatient care (for either the mother or child) which continues beyond the 48/96 hour limits stated above,
UnitedHealthcare must be notified before the end of these time periods.
Non-Emergency Inpatient Confinement Without Delivery of Child: Confinement during pregnancy
but before the admission for delivery, which is not Emergency Care, requires notification as a scheduled
confinement. UnitedHealthcare must be notified prior to the scheduled admission.
For Outpatient services
For outpatient services which require notification, you must notify UnitedHealthcare at within five (5) working
days before the service is given.
For Organ/Tissue Transplants
UnitedHealthcare must be notified at least seven (7) working days before the scheduled date of any of the
following (or as soon as reasonably possible):
The evaluation
The donor search
The organ procurement/tissue harvest
The transplant
UnitedHealthcare will complete a review of these services soon after being notified of these services. You and
your Physician as well as the facility where the service is being performed will be sent a letter confirming the
results of the review.
For Emergency Care
When Emergency care is required and results in confinement, you, your network physician, a responsible net
work hospital staff member or a family member must contact UnitedHealthcare within two (2) working days
of your hospital admission date. Working days do not include Saturdays, Sundays, State or Federal holidays.
If it is not reasonably possible to contact UnitedHealthcare within two working days due to the health circumstances of the patient, UnitedHealthcare must be notified as soon as reasonably possible.
Please be advised that if your physician recommends additional services for you after Emergency Care has ended,
UnitedHealthcare must be contacted before you receive any additional services that require notification. Benefits
are subject to the Non-Notification Penalty if notification is not obtained. The Non-Notification Penalty applies
to each confinement. The amount of the Non-Notification Penalty is in accordance with the Summary of Benefits, but will never be more than the amount of the Covered Expenses .
For Mental Disorder Treatment
Notification Requirement: You are required to call UnitedHealthcare’s Behavioral Health Care
Management (BHCM) department BEFORE Covered Services and Supplies are given on an inpatient basis
for Mental Disorder Treatment. This includes Hospital or Treatment Center confinement. The Review
process is initiated by calling BHCM.
BHCM can be contacted by calling the toll-free number in the directory of providers, or by calling the
Customer Service at the toll-free number shown on your ID card.
BHCM performs a review to determine the Medical Necessity of Covered Services and Supplies. No benefits are payable unless BHCM determines the Covered Services and Supplies are Medically Necessary.
Emergency Care: When Emergency Care is required for Mental Disorder Treatment, you (or a representative or Physician) must call BHCM within one day (24 hours) after the Emergency Care is given. BHCM is
ready to take calls 7 days a week, 24 hours a day. If it is not reasonably possible to make this call within
one calendar day, the call must be made as soon as reasonably possible.
When the Emergency Care has ended, BHCM must be called BEFORE any additional services are received.
Appeals: You have the right to appeal a Review– contact BHCM for further information at the toll-free
number shown on your ID card .
SPECIFIC EXAMPLES OF PROCEDURES THAT REQUIRE ADVANCE NOTIFICATION
The following chart outlines certain services that require notification to UnitedHealthcare. Advance notification to
UHC must be provided within (14) days of the service for ‘non-emergency care’ and as soon as practicable for
‘emergency’ care.
TYPE OF SERVICE
IMPORTANT NOTES
Accidental Dental Services
Notification is required for Benefit Coverage Decision.
‘Non-notification penalty’ will be imposed if notification is
not provided to UHC
Blepharoplasty, Upper Lid
Requires notification for benefit coverage decision
Breast Reconstructive Procedures
Requires notification for benefit coverage decision when performed for reasons other than following surgery for cancer.
Breast Reduction
Requires notification for benefit coverage decision
Durable Medical Equipment> $1000
DME with a retail cost of over $1000 (whether for purchase
or for rental) requires notification. Must utilize network providers if a network provider is available. Verification of
whether coverage is available. Non-notification penalty will
be imposed if notification is not provided to UHC.
End Stage Renal Disease Services
Notification is required for federal tracking only
Home Health Care Services
Pre-notification is required for Benefit Coverage Decision for
all home based services, including nursing, respiratory
therapy, IV infusion services and hospice. Non-notification
penalty will be imposed if pre-notification is not provided to
UHC .
Inpatient Facility Admissions
This includes all inpatient admissions including acute hospital, rehabilitation facilities and skilled nursing facilities.
Also includes Maternity admissions that exceed the federally
mandated length of stay of 48 hours for vaginal delivery or 96
hours for cesarean delivery.
If an Emergency admission to a Non-network provider
occurs, you need to contact UnitedHealthcare within
two (2) business days.
Non-notification penalty will be
pre-notification is not provided to UHC .
imposed
if
Cardiac Rehabilitation
Advance notification required for Benefit Coverage Decision
Dialysis
Advance notification required for Benefit Coverage Decision
Out-of-Network Services
Advance notification is required for Benefit Coverage Decision in cases of referrals to out-of-network providers and
hospitals who request in-network reimbursement.
Oral Surgery (Middle Tier and Non-Network)
Advance Notification required for Benefit Coverage Decision
Physical, Occupational and Speech Therapies
Notification required for Benefit Coverage Decision
Sclerotherapy
Notification required for Benefit Coverage Decision
Transplant Services
Notification required for Benefit Coverage Decision
Vein Stripping, Ligation
Notification required for Benefit Coverage Decision
Care Coordination During Emergency Cases
When Emergency Care is required and results in a confinement, the Covered Person (or that person’s representative or
Physician) must call Care Coordination within 48 hours of the date the confinement begins.
A working day is a business day of the Company. It does not include Saturday, Sunday, or a state or federal holiday.
If it is not reasonably possible to call Care Coordination within 48 hours, Care Coordination must be notified as soon as
reasonably possible.
When the Emergency Care has ended, Care Coordination must be called before any additional services that require
notification are received.
Benefits are subject to the $400 Non-Notification Penalty if Care Coordination is not called within 48 hours or
as soon as reasonably possible (if it is not reasonably possible to contact Care Coordination within 48 hours).
The amount of the Non-Notification Penalty will never be more than the amount of the Covered Expenses.
Steps To Appeal Decisions Related to Care Coordination Review
If you and/or your physician do not agree with Care Coordination’s decision regarding your claim for benefits for a
procedure that required notification, you and/or your physician can request that Care Coordination reconsider the decision.
For further information refer to the ‘Claims Information’ section in this booklet.
COVERED SERVICES AND SUPPLIES
Covered Services and Supplies must be Covered Health Services under the UnitedHealthcare PPO plans offered by
NYUHC. They must also be given for the diagnosis or treatment of an accidental injury or illness which are medically necessary. You and/or your Physician decide which services and supplies are given, but the Plan only pays for
the Covered Services and Supplies which are deemed Covered Health Services by UnitedHealthcare.
Covered Services and Supplies also include services and supplies that are part of an Alternate Care Proposal (ACP).
An ACP is a course of treatment developed by UnitedHealthcare as an alternative to the services to the services and
supplies that would otherwise been considered to be covered. Unless the ACP specifies otherwise, the provisions of
the plan related to benefit amounts, maximum amounts, copayments and deductibles will apply to these services.
THE FOLLOWING ARE COVERED SERVICES AND SUPPLIES BASED ON MEDICAL NECESSITY
UNDER THE UNITEDHEALTHCARE PPO PLANS*:
Note: Covered services are subject to limits, co-pays , co-insurance and certain services may not be covered out-of-network (see UnitedHealthcare Benefits Summaries for the PPO
Plans in this booklet)
Allergy Care
Initial visit and all subsequent referral visits are subject to office visit co-pay– except for visits for injection only
(co-pay is waived)
Ambulance Services
Covered under the Plan at 100% if medically necessary.
Ambulatory Surgical Center Services
A Center’s services given within 72 hours before or after a surgical procedure. The services must be given in
connection with the procedure.
Anesthesia
Anesthesia and its administration are covered
Artificial Limbs
Once in a lifetime benefit if original not provided by UHC (one temporary and one permanent for same extremity)subsequent prostheses will only be covered for children as a result of growth or based on medical necessity.
See Durable Medical Equipment in this section for repairs of artificial limbs.
Autism Spectrum Disorder
Provides coverage for screening, diagnosis and treatment of autism spectrum disorder including:
-behavioral health treatment (such as behavioral analysis)
-psychiatric care
-psychological care
-therapeutic care, including non-restorative therapy provided by licensed or certified speech therapists, occupational therapists, social workers, or physical therapists
-augmentative communication devices
Any other medical care provided by a licensed health care provider
No age gaps or visit limits with a diagnosis of Autism Spectrum Disorder
Provides coverage for applied behavior analysis provided or supervised by a Board Certified Behavior Analyst
up to $45,000 a year.
Chemotherapy
Chemotherapy and its administration.
Durable Medical Equipment
Durable Medical Equipment means equipment which meets all of the following criteria:
It is for repeated use and is not a consumable item.
It is used primarily for a medical purpose.
It is appropriate for use in the home.
Some examples of Durable Medical Equipment are:
Appliances which replace a lost body organ or part or help an impaired one to work.
Orthotic devices such as arm, leg, neck and back braces.
Hospital-type beds.
Equipment needed to increase mobility, such as a wheelchair.
Respirators or other equipment for the use of oxygen.
Monitoring devices.
Payment for all Durable Medical Equipment, Prosthetics and artificial aids will be subject to medical management review and is subject to a Lifetime Maximum of $50,000 for each Covered Person. Foot orthodics
are limited to $250 per foot, per Lifetime.
Enteral Nutrition
Non-prescription enteral formulas for home use for which a Physician has issued a written order. The order
must state that the enteral formula is medically necessary as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic
physical disability, mental retardation or death. Specific diseases for which enteral formulas have been proven
effective include, but are not limited to, inherited diseases of amino acid or organic acid metabolism; Crohn’s
disease; gastroesophageal reflux with failure to thrive; disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction; and multiple, severe food allergies. This does not include nutritional supplements
that are taken electively.
Foot Care
Care and treatment of the feet, if needed due to severe systemic disease. Routine care such as removal of warts,
corns, or calluses, the cutting and trimming of toenails, foot care for flat feet, fallen arches, and chronic foot strain is a
Covered Service only if needed due to severe systemic disease.
Hearing Aids
Subject to maximum of $350 per 24 months
Home Health Care
The following covered services must be given by a licensed Home Health Care Agency (does not need to be associated with a hospital stay).
Temporary or part-time nursing care by or supervised by a registered graduate nurse (R.N.) or (L.P.N)
Temporary or part-time care by a home health aide
Physical therapy
Occupational therapy
Speech Therapy
Nutritional or psychological counseling and respiratory therapy billed by the home health agency would be
covered. Mental Health visits go toward Mental Health maximum benefit.
Home Health Care (con’t)
Medical supplies, IV or injectable drugs and medication prescribed by MD and billed through home health
agency.
Laboratory services to the extent that such items would be available if member would have been hospitalized or
in a skilled RN facility.
Covered services are limited to (200) visits each Calendar year. Each period of home health aide care of up to
(4) hours in the same day counts as one visit. Each visit by any other member of the home health team will count as
one visit.
Hospice Care
Room and Board
Other services and supplies
Part-time nursing care by or supervised by a registered graduate nurse (R.N.).
Home Health Care Services as shown under Home Health Care. The limit on the number of visits shown under
Home Health Care does not apply to Hospice patients.
Counseling for the patient and covered dependents
Coverage for integrated program of palliative and support services for pain control and acute or chronic symptom management. It includes physical, psychological, and social work care administered and billed by a licensed
hospice agency or program (spiritual care is not covered).
Bereavement counseling for covered dependents. Services must be given within six (6) months after the
patient’s death. Covered services are limited to a total of (15) visits for each family member. Counseling
must be given by a Licensed Counselor. ‘Group counseling’ services would be charged to one family member’s
visit limit.
Services for the patient must be given in an inpatient Hospice facility or in the patient’s home. The Physician
must certify that the patient is terminally ill with an expectation of six (6) months or less to live. Any counseling
services given in connection with a terminal illness will not be considered as Mental Disorder Treatment.
Charges for services not billed by hospice agency would not be covered unless individual is a licensed professional (i.e physician responsible for case management or consultative services).
Covered Services are limited to (210) inpatient Hospice visits per lifetime. There is no limitation on outpatient Hospice visits.
Inpatient Hospital Services
Room and board.
Covered Expenses for a private room are limited to the regular daily charge made by the Hospital for a
semi-private room.
Other services and supplies deemed medically necessary
Emergency Room
Emergency room services are covered only if it is determined that the services are Covered Health services and
there is not a less intensive or more appropriate place of service, diagnostic or treatment alternative that could
have been used in lieu of emergency room services.
Infertility Treatment
Treatment of underlying condition: Once diagnosed, all eligible expenses related to the treatment of the underlying
condition causing the infertility will be covered whether the eligible treatment services are received through in-network
or out-of-network providers.
Reproductive Services (limited to a lifetime maximum of $10,000)
Coverage for in-network reproductive services are covered, but limited to a lifetime maximum of $10,000.
Reproductive services are NOT covered when performed by out-of-network providers
Artificial Insemination
Covered Services and Supplies are limited to artificial insemination up to four (4) times each month for one sixmonth period in the Covered Person’s lifetime.
Artificial Insemination procedures are subject to the overall lifetime maximum of $10,000 for Infertility
Treatments when performed by in-network providers. Artificial insemination procedures performed by
out-of-network providers are not covered under the Plan.
Assisted Reproductive Technology
Covered Services and Supplies for Assisted Reproductive Technology (ART) are limited to a Covered Person who
has undergone extensive screening and has been selected for ART because:
The ART is safe and effective according to accepted clinical evidence reported by generally recognized medical professionals or publications.
There is not a less intensive or more appropriate diagnostic or treatment alternative that could have been used in lieu of
the following assisted reproductive technology procedures:
Invitro fertilization services (IVF)
Gamete intrafallopian transfer (GIFT)
Zygote intrafallopian transfer (ZIFT)
Microinjection techniques
The Covered Person must have been unable to become pregnant through more conservative means for a minimum of
12 months, unless one partner has already been diagnosed as infertile.
ART Not Covered:
More than three attempts at ART.
ART if infertility is the result of voluntary sterilization.
Exclusions and Limitations that apply to these benefits are also noted in the ‘General Exclusions and Limitations’ section of this Summary Plan Description.
Note on Infertility Drug Therapy Coverage: Drug therapy relating to infertility is NOT covered under the
UnitedHealthcare PPO plans, with the exception of certain injectables. Limited coverage for infertility drugs is
provided under the Prescription Drug Plan (refer to section on ‘The Prescription Drug Plan’ in this booklet).
Laboratory Tests and X-rays
X-rays or tests for diagnosis or treatment
Medical Supplies
Coverage for medical supplies is provided when medically necessary. This includes disposable, non-reusable
medical supplies and used in treatment or maintenance of a medical condition that is short-term or chronic in nature. Ace bandages, ostomy, catheters, paper tape, wheelchair cushions, chemical strips, etc. Supplies can be purchased at a pharmacy, drug store, or participating provider.
Surgical supplies (such as bandages and dressings). Supplies utilized during surgery or a diagnostic procedure
are included in the overall cost for that surgery or diagnostic procedure. Coverage for surgical supplies under
the plan is provided on both an inpatient and outpatient basis.
Blood or blood derivatives only if not donated or replaced.
Medical Transportation Services
The following services must be given within the United States, Puerto Rico or Canada:
Transportation by professional ambulance, other than air ambulance, to and from a medical facility.
Transportation by regularly-scheduled airline, railroad or air ambulance, to the nearest medical facility qualified to
give the required treatment.
Please be advised that Air Transportation is covered under the plan for in emergency cases outside the
United States.
Nurse Practitioner Services
Services of a licensed or certified Nurse-Practitioner acting within the scope of that license or certification.
Oral Surgery and Dental Services
Oral surgery if needed as a necessary, but incidental, part of a larger service in treatment of an underlying medical
condition.
The following services and supplies are covered only if needed because of accidental injury to natural teeth,
mouth, jaw bones, or surrounding tissues/bones/muscles :
Oral Surgery
Full or partial dentures
Fixed bridge work
Prompt repair to natural teeth
Crowns
The correction of a non-dental physiological condition which has resulted in severe functional impairment;
treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and
floor of mouth.
Treatment of a fracture, dislocation or wound, treatment needed to remove, repair, replace or restore or
reposition sound and natural teeth which have been damaged, lost or removed, or other body tissues of the
mouth which have been fractured or cut due to injury (except those accidents related to biting or chewing),
under the following conditions:
the accident causing the injury occurs while the person is covered under the Plan
any affected teeth must be either free from decay or in good repair and firmly attached to the jaw bone at
the time of injury
the treatment must be done in the calendar year of the accident or the following year.
If crowns, dentures, bridgework or in-mouth appliances are installed due to such injury, covered medical
expenses include only charges for the first denture or fixed bridgework to replace lost teeth; the first
crown needed to repair each damaged tooth; and in-mouth appliance used in the first course of orthodontic treatment after the injury.
Organ/Tissue Transplants
The evaluation
The donor search
The organ procurement/tissue harvest
The transplant procedure
Services and supplies for necessary organ or tissue transplants are payable under this plan for those transplants considered non-experimental and non-investigational. Notification of the need for organ/tissue transplant is required in
accordance with pre-notification procedures (refer to section on ‘Notification for Care Coordination Under the
PPO Plans’ in this booklet).
Donor Charges for Organ/Tissue Transplants
In the case of an organ or tissue transplant, donor charges are considered Covered Expenses ONLY if the
recipient is covered under the UnitedHealthcare PPO medical plans offered by NYUHC. If the recipient is not
covered under one of the UnitedHealthcare PPO plans, no benefits are payable for donor charges.
The search for bone marrow/stem cell from a donor who is not biologically related to the patient is not considered a
Covered Service UNLESS the search is made in connection with a transplant procedure arranged by a Designated
Transplant Facility.
If a Qualified Procedure, listed below, is a Covered Health Service and performed at a Designated Transplant Facility, the ‘Medical Care and Treatment’ and ‘Transportation and Lodging’ provisions described below apply:
Qualified Procedures
Heart Transplants
Lung Transplants
Heart/Lung Transplants
Liver Transplants
Kidney Transplants
Pancreas Transplants
Kidney/Pancreas Transplants
Bone Marrow/Stem Cell transplants
Other transplant procedures when UnitedHealthcare determines that it is medically appropriate to perform the
procedure at a Designated Transplant Facility.
Medical Care Treatment
The Covered expenses for services provided in connection with the qualified transplant procedures listed above include:
Pre-transplant evaluation for one of the procedures listed above
Organ acquisition and procurement
Hospital and Physician fees
Transplant procedures
Medical Care Treatment (con’t)
Follow-up care for a period up to one year after the transplant
Search for bone marrow/stem cell from a donor who is not biologically related to the patient. If a separate
charge is made for bone marrow/stem cell search, a Maximum Benefit of $25,000 is payable for all charges
made in connection with the search.
Donor hospitalization: Pre-donation & hospitalization are covered under the Plan if benefits are not provided
for any donor expenses under another group plan.
Transportation and Lodging
UnitedHealthcare’s Care Coordination department will provide assistance to the patient and family with travel and
lodging arrangements for the qualified procedures listed above. Expenses for travel, lodging and meals for the transplant recipient and a companion are covered as follows:
Transportation of the patient and one companion who is traveling on the same day(s) to and/or from the site of
the transplant for the purposes of an evaluation, the transplant procedure or necessary post-discharge follow-up.
Reasonable and necessary expenses for lodging and meals for the patient (while not confined) and one companion. Benefits are paid at a per diem rate of up to $50 for one person or up to $100 for two people.
Travel and lodging expenses are only available if the transplant recipient resides more than 50 miles from the
Designated Transplant Facility.
If the patient is a covered dependent minor child, the transportation expenses of two companions will be
covered and lodging and meal expenses will be reimbursed up to the $100 per diem rate.
There is a combined overall lifetime maximum of $10,000 per Covered Person for all transportation, lodging and meal expenses incurred by the transplant recipient and companion(s) and reimbursed under the plan in
connection with all transplant procedures.
Orthoptic Training (Eye Muscle Exercises)
Training by a licensed optometrist or an orthoptic technician.
Ostomy Supplies
Coverage for ostomy supplies is provided when medically necessary. Supplies can be purchased at a pharmacy, drug
store, or participating provider.
Outpatient Cardiac Rehabilitation
Outpatient cardiac rehabilitation services are limited to (90) visits per lifetime.
Outpatient Pulmonary Rehabilitation
Outpatient pulmonary rehabilitation services are limited to (90) visits per lifetime.
Outpatient Occupational Therapy
Services of a licensed occupational therapist, provided the following conditions are met:
The therapy must be ordered and monitored by a Physician .
The therapy must be given in accordance with a written treatment plan approved by a Physician. The therapist
must submit progress reports at the intervals stated in the treatment plan.
The therapy must be expected to result in significant, objective, measurable physical improvement in the Covered Person’s condition within two (2) months of the start of the treatment
Covered Services for Outpatient Occupational Therapy are limited to (90) visits per condition per lifetime.
Outpatient Physical Therapy
Services of a licensed physical therapist, provided the following conditions are met:
The therapy must be ordered and monitored by a Physician.
The therapy must be given in accordance with a written treatment plan approved by a Physician. The therapist
must submit progress reports at the intervals stated in the treatment plan.
The therapy must be expected to result in significant, objective, measurable physical improvement in the Covered Person’s condition within two (2) months of the start of the treatment
Covered Services are limited to (90) visits per condition per lifetime and are limited to three (3) types of
treatment to each body part during each visit.
Physician Services
Medical Care and Treatment
Hospital, office and home visits
Emergency room services
Surgery
Services for surgical procedures.
Reconstructive Surgery
Coverage will be provided in a manner determined as follows:
Reconstruction surgery to improve the function of a body part when the malfunction is the direct result of one
of the following:
Birth defect
Illness
Surgery to treat a sickness or accidental injury
Accidental injury
Reconstructive breast surgery following a necessary mastectomy.*
Reconstructive surgery to remove scar tissue on the neck, face, or head if the scar tissue is due to illness or accidental injury.
Cosmetic procedures are excluded from coverage. Procedures that correct a congenital anomaly without
improving or restoring physiologic function are considered cosmetic procedures. The fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a result of an injury, illness or congenital anomaly does not classify surgery or other procedures done to relieve such consequences or behavior as
a reconstructive procedure.
*Information regarding reconstructive breast surgery following a mastectomy, refer to the ‘Notice on
‘The Women’s Health and Cancer Rights Act of 1998’ in this booklet.
Assistant Surgeon Services
Covered Expenses for assistant surgeon services are limited to 1/5 of the amount of Covered Expenses for the surgeon’s charge for the surgery. An assistant surgeon must be a Physician. Surgical assistant’s services are not covered.
Multiple Surgical Procedures
Multiple surgical procedures means more than one surgical procedure performed during the same operative session.
Covered Expenses for multiple surgical procedures are limited as follows:
Covered Expenses for a secondary procedure are limited to 50% of the Covered Expenses that would otherwise be
considered for the secondary procedure had it been performed during a separate operative session.
Covered Expenses for any subsequent procedure are limited to 25% of the Covered Expenses that would otherwise
be considered for the subsequent procedure had it been performed during a separate operative session.
Separate incision, different operative field– full benefit allowed per procedure.
Incidental procedures– which do not add significantly to the time and complexity of primary surgery– do not
warrant full charge for each separate procedure.
Laproscopic procedure with multiple incisions covered as one procedure.
Prescribed Drugs and Medicines
Prescribed Drugs and Medicines during a covered Hospital stay.
Radiation Therapy
Inpatient and outpatient radiation treatment by licensed radiation therapy provider.
Rehabilitation Therapy
Inpatient Rehabilitation Therapy
Services of a Hospital or Rehabilitation Facility for room, board, care and treatment during a confinement.
Inpatient rehabilitative therapy is a Covered Service only if intensive and multidisciplinary rehabilitation care
is necessary to improve the patient’s ability to function independently.
Covered Services are limited to a combined total of 200 days of confinement in a Hospital, Skilled Nursing
Facility and/or Rehabilitation Facility each Calendar Year.
Outpatient Rehabilitation Therapy - Services provided in a Hospital or Comprehensive Outpatient Rehabilitation Facility (CORF).
Covered Services are limited to 90 days of therapy per lifetime. A day of therapy includes all services
given by visits to the Hospital or CORF in any one day.
Covered Services for each day of therapy reduces the number of visits under Covered Services for Outpatient
Physical Therapy, Outpatient Occupational Therapy, or Speech Therapy . This reduction only applies to days
of therapy during which the therapy includes services given by a physical therapist, occupational therapist or
speech therapist.
Skilled Nursing Facility Services
▪
Room and board. Covered Expenses for Room and board are limited to the facility’s regular daily charge for a
semi-private room.
Other Services and Supplies related to confinement which are medically necessary. Covered Services are
limited to the first 200 days of confinement each Calendar Year.
Speech Therapy
Services of a licensed speech therapist for restorative speech therapy only. These services must be given to restore
speech lost or impaired due to one of the following:
▪
▪
▪
▪
Surgery, radiation therapy or other treatment which affects the vocal chords
Cerebral thrombosis (cerebral vascular accident)
Brain damage due to accidental injury or organic brain lesion (aphasia)
Accidental injury
The therapy must be expected to result in significant, objective, measurable physical improvement in the Covered Person’s condition within two (2) months of the start of treatment. Covered Services are limited to 90 visits per condition per lifetime.
Speech Therapy for Children
Services of a licensed speech therapist for restorative speech therapy given to a child to restore speech lost or
impaired. Coverage provided under the Plan is limited only to “restorative” speech therapy. Covered Services are
limited to (90) visits per condition per Lifetime.
Note: No coverage is provided under the Plan for “educational therapy” or therapy for “learning disabilities”
or “developmental delays”.
Important Note Regarding Speech Therapy/Special Education Services for Children:
If your child experiences developmental delays such as difficulty with speech, mobility, cognitive and learning skills, or facing
physical or behavioral challenges, coverage for specially planned instructional services may be available to your child through
a state-sponsored special education program in conjunction with other municipalities.
For example, The New York State Education Department (SED), Office of Vocational and Educational Services for Individuals with Disabilities (VESID) oversees a statewide special education program with school districts, municipalities,
approved providers and parents (for more information on the Special Education Program in New York State, visit the
VESID website at www.vesid.nysed.gov/specialed).
Please be advised that if your child is eligible and approved to receive services under a special education program
provided by the state or education system, those services are NOT eligible for coverage under the UnitedHealthcare PPO Plan as the Plan does not provide coverage for treatment, services or supplies that any government or
subdivision of government (including government hospitals) provides and pays for or reimburses.
Furthermore, the Plan only provides coverage for psychological testing for “learning disabilities” or
“developmental delays” when such services are NOT available and provided by the state or education system.
No coverage is provided under the Plan “for educational therapy” or any therapy related to treating “learning disabilities or “developmental delays” .
For further information on the special education programs available in your state of residence, please contact your
local school district board.
Spinal Manipulations (or Chiropractic Care)
Services of a provider given for the detection or correction (manipulation) by manual or mechanical means of structural
imbalance or distortion in the spine.
Covered Services are limited to $1,000 per Calendar Year for each Covered Person.
Only chiropractic manipulative treatment codes are counted toward the manipulative treatment visit limit, regardless of provider type.
Office visits and diagnostics (labs, xrays, etc.) are covered the same as any other office visit or diagnostic service
and do not count toward the manipulative treatment visit limit.
Physical therapy/physical therapy modalities do not count toward the manipulative treatment visit limit.
TMJ
Surgery to correct Temporo-Mandibular Joint (TMJ) disorders is covered under the Plan. However coverage is not
provided for therapy treatments related for TMJ disorders.
Wigs (resulting from chemotherapy/radiation therapy treatments)
For plan participants who are in need of a wig due to chemotherapy/radiation therapy treatments, coverage is provided
under the Plan for (2) wigs up to a lifetime limit of $750 for each wig.
Please be advised that wigs or toupees, hair transplants, or used in connection with baldness, loss of hair due to other
treatments or for cosmetic purposes are NOT covered under the Plan (see ‘General Exclusions and Limitations’ in
this booklet).
Mental Health Benefits
Mental Health Benefits are subject to the same co-payments, deductibles and percentage of Covered Expenses payable
as benefits that are paid due to physical illnesses, except as shown in the Schedule of Benefits outlined in the ‘Benefit
Summaries for the UHC PPO Plans’ .
Mental Health/Substance Abuse Benefits include, but are not limited to:
Assessment
Diagnosis
Treatment Planning
Medication management
Individual, family and group psychotherapy
Services provided by a licensed Psychologist; psychological education, and psychological testing*
*The Plan only provides coverage for psychological testing for “learning disabilities”, “developmental
delays”, or “educational therapy” when such services are NOT available and provided by the state or edu
cation system. No coverage is provided under the Plan for “education therapy” or any therapy related to t
reating “learning disabilities” or “developmental delays”.
Note on Outpatient Mental Health Visits and Out-of-Pocket Maximums:
Co-payments incurred for ‘In-Network’ Outpatient Mental Health Visits count towards the ‘In-Network’ Out-ofPocket Maximum. Once the ‘In-Network’ Out-of-Pocket Maximum is reached, benefits for In-Network Outpatient
Mental Health Visits are payable at 100%.
However, co-payments incurred for ‘Out-of-Network’ Outpatient Mental Health Visits do NOT count toward the
‘Out-of-Network’ Out-of-Pocket Maximum. Furthermore, if the ‘Out-of-Network’ Out-of-Pocket Maximum is
reached, benefits for Out-of-Network Outpatient Mental Health Services are NOT payable at 100%.
Additional Covered Services and Supplies specific to Mental Disorder Treatment are listed below. These
Additional Covered Services are subject to the same requirements as Covered Services and Supplies listed for
Medical Benefits.
Additional Covered Services and Supplies
Licensed Counselor Services
Services of a Licensed Counselor for Mental Disorder Treatment.
Treatment Center Services
Room and Board.
Other Services and Supplies which are medically necessary
Exclusions and limitations that apply to these benefits are noted in the ‘General Exclusions and Limitations’
section of this Summary Plan Description.
Impact of The Mental Health Parity and Addiction Equity Act
The Mental Health Parity and Addiction Equity Act of 2008 (effective for calendar year plans on January 1,
2010) was enacted to make mental and substance abuse coverage comparable to how medical and surgical
benefits are administered under Medical Plans. Although the law does not require plans to provide mental health
and substance abuse disorder benefits if they do not already do so, the Act requires Employers to make necessary
changes to their plans with respect to their cost structures and provisions to become compliant with this new legislation.
Prior to the enactment of the Mental Health Parity Act, limits were placed on the number of visits that would be covered for services relating to mental health under the PPO plans. However, effective January 1, 2010, changes were
made to the Mental Health benefits offered under PPO plans (where applicable) to ensure that mental health and
coverage is comparable to medical and surgical benefits provided under PPO plans for that PPO plan option (i.e
Basic or Plus option).
NYUHC made the following improvements to the UnitedHealthcare PPO plans effective January 1, 2010:
► The limitation on covered visits for the number of out-patient mental health visits was eliminated.
► The $50 maximum reimbursement amount per out-patient visit was also eliminated . Reimbursement is now based on
whether your provider is in-network or out-of-network.
In-Network: You now pay the same co-pay when accessing in-network providers for your mental health visits that you
pay for medical office visits ($30 under the Plus PPO or $40 under the Basic PPO).
Out-of-Network: After you meet a lower annual deductible amount for out-patient mental health care services, the
reimbursement is now the same as it is for other out-of-network medical services you receive, as outlined below:
o Only $500 of the $1200 per person annual deductible has to be met before your out-patient mental health benefits
begin to be paid at the Plan’s regular reimbursement rate. Any medical expense applied to the annual deductible
counts towards the lower $500 amount, not just expenses incurred for mental health.
o Upon meeting the $500 deductible amount, the PPO Plus Plan pays 60% of the allowable charge (50% paid by the
Basic PPO Plan) of the plan’s allowable charge, based on the MNRP allowance determined by United HealthCare)
How To Obtain Authorization for Out-Patient Mental Health Visits
Whether you use a participating provider (in-network) or you seek care outside of the United Healthcare network, you
must obtain certification first in order to ensure that a proper treatment plan is in place.
In-Network
Members must call United Behavioral Health prior to treatment to secure an open certification which allows them to seektreatment from any participating network provider for up to 12 months from the date of the certification. During treatment, the patient will receive a wellness assessment to complete at certain treatment intervals, which is important for treatment planning.
Out-of-Network
Members must call United Behavioral Health prior to treatment to secure a provider specific certification for the first 10
visits. Prior to the 10th visit, the provider will need to obtain and submit to United Behavioral an out-patient treatment plan
review form. This information can also be completed by the provider via telephone.
Based on the plan submitted, authorization for additional out-patient visits may be granted (typically approved for 6-10 additional visits per review). This process will need to be completed again if further treatment is needed beyond the visits authorized until the member has completed the outpatient treatment
Note on Substance Abuse Benefits
Substance abuse benefits under the plan were also amended to align with the applicable co-pays, coinsurances and
provisions that apply to medical and surgical benefits under the plan to ensure equity and consistency in the way these
benefits are covered under the Plan (see the Mental Health Benefits and Substance Abuse benefits outlined in the
UnitedHealthcare PPO Benefits Summaries in this booklet).
Pregnancy Benefits
Benefits are payable for Covered Services and Supplies for pregnancy given to the Covered Person while covered
under this Plan. Benefits for pregnancy are paid in the same way as benefits are paid for medical illness.
Benefits are payable for at least:
(48) hours of inpatient care for the mother and newborn child following a normal vaginal delivery.
(96) hours of inpatient care for the mother and newborn child following a cesarean section.
The Hospital or other provider is not required to get authorization from UnitedHealthcare for the time periods stated
above. Authorizations are required for longer lengths of stay.
Federal law does not prohibit the mother’s or newborn’s attending Physician, after consulting with the mother, from
discharging the mother or her newborn child earlier than 48 hours (or 96 hours, as applicable).
In-Network routine hospital nursery services for the newborn baby during the mother’s covered stay will not be subject to a deductible and coinsurance under the Plan and will be covered at 100%.
The office visit copayment does not apply to prenatal and postnatal in-network office visits (after the initial diagnosis)
by the Network obstetrician/gynecologist who is primarily responsible for the patient’s maternity care.
However, in-network pre/post-natal care and hospital services for the mother will still be subject to the in-network
coinsurance, in-network deductible and in-network hospital co-payment (if applicable).
Out-of-Network hospital nursery services for the newborn baby during the mother’s covered stay as well as the
mother’s out-of-network pre/post-natal services will be subject to the out-of-network coinsurance, out-of-network
deductible and out-of-network hospital admission co-payment .
Additional Covered Services and Supplies Under Pregnancy Benefits
Birth Center Services
Room and Board
Other Services and Supplies medically necessary
Anesthesia
Nurse-Midwife’s Services
Services of a licensed or certified Nurse-Midwife
Routine Well Baby Care
The following services and supplies given during a newborn child’s initial Hospital confinement:
Hospital services for nursery care.
Other Services and Supplies given by the Hospital.
Services of a surgeon for circumcision
Physician Services
Exclusions and limitations that apply to these benefits are also noted in the ‘General Exclusions and Limitations’
section of this Summary Plan Description .
Family Planning Benefits
Benefits are payable for Covered Expenses for Family Planning Benefits incurred by the Covered Person while covered under this plan. A Covered Expense is incurred on the date that the Covered Service or Supply is performed or
given. These Family Planning Benefits are subject to the same co-payments, deductibles and percentage of Covered
Expenses payable as benefits that are paid due to illness under Medical Benefits. After coverage under this Plan
stops, there are no extended benefits.
Covered Services and Supplies under Family Planning Benefits
Contraceptive Drugs, Services and Devices*
Contraceptive drugs, services and devices are covered under the Plan at both the in-network and out-ofnetwork level, provided that they are billed as part of a procedure visit. If billed as separate charges they
will not be covered under the Plan.
Contraceptive Drugs, Services, and Devices covered under the Plan include but are not limited to:
Diaphram and intrauterine device and related Physician services
Voluntary sterilization by either vasectomy or tubal ligation
Contraceptives requiring physician administration, including injectables such as Depo-Provera
Surgical implants for contraception, such as Norplant
* Important Note :
Oral contraceptives and birth control patches are NOT covered under the UnitedHealthcare PPO plans. Coverage is
provided for oral contraceptives and birth control patches under the Prescription Drug Benefit administered by
CVS/Caremark (refer to section on ‘The Prescription Drug Plan’ in this booklet).
Preventive Health Care Benefits
Benefits are payable for Covered Services and Supplies for Preventive Health Care Benefits when provided to a
Covered Person by either a Network Physician or an Out-of-Network Physician. However, the Plan pays a greater
portion of the Covered Expense if the person receives the services from a Network Physician. The Covered Person
must be covered under this Plan on the date the Covered Service or Supply is performed or given.
Outlined on the following pages is a comprehensive list of Preventive Health Services that are covered at
100% under the UnitedHealthcare PPO Basic and Plus Plans when performed by a Network Provider.
In-Network preventive health services are NOT subject to the “in-network” deductible and co-insurance
under the UnitedHealthcare PPO Basic and Plus Plans.
Out-of-network preventive health services will be subject to the out-of-network deductible and coinsurance.
Benefits are payable for Preventive Health Care services obtained on an ‘Out-of-Network’ basis according to the
Schedule of Benefits (refer to UnitedHealthcare PPO Benefit Summaries in this booklet). After coverage under
this Plan stops, there are no extended benefits .
Expanded Coverage for Women’s Preventive Health Services
The Patient Protection and Affordable Care Act (PPACA)
New guidelines under PPACA require health plans to cover an expanded list of women’s preventive health services at
100% (i.e without charging co-payments, co-insurance amounts, or applying deductibles). In compliance with the
guidelines, the PPO plans cover the expanded list of preventive services for women at 100% (see list below):
Expanded coverage for Women’s Preventive Health Services covered at 100% effective 1/1/2013 includes:
Well-woman visits
Gestational diabetes screening for pregnant women
Domestic and interpersonal violence screening and counseling
FDA-approved contraception methods, and contraceptive education and counseling
Breastfeeding support, supplies, and counseling
HPV DNA testing, for women 30 or older
Sexually transmitted infections counseling
HIV screening and counseling for sexually-active women
Adult Preventive Services (in-network)- applicable for patients age 18 & above
Type of Service
Coverage
Note on Diagnostic Tests: Certain preventive tests such as ultrasounds, MRIs, mammography, needle biopsies of the breast,
pathology related to Colonoscopy for certain cancers are covered “in-network” only
Physical Examination
Once per calendar year
Blood Pressure Screening
Coincides with physical examination once per calendar year
EKG– standard non-stress
Coincides with physical examination once per calendar year
Pap Smear (females)
Once per calendar year (includes sexually active females 11
through 21 guideline)
Urinalysis
Coincides with office visit
Cholesterol Screening
Coincides with physical examination once per calendar year
Chlamydia Screening
Screening recommended for all sexually active females 11-24;
sexually active females age 25 and up at high risk for infection.
This would allow coverage annually as a preventive screening.
Mammogram (females: baseline age 35-40)
One baseline mammogram is covered at 100% under the
plan for females between ages 35-40. This benefit applies
to routine mammograms.
Subsequent non-routine mammograms performed during
the calendar year will be subject to the in-network
deductible and coinsurance.
Note: Mammograms for women under age 35 will be
covered at 100% provided there is a family history of
disease or a disease state diagnosis.
Mammogram (females: annual, ages 40 & above)
Preventative mammogram charges (both professional and
technical components) are covered at 100% once per calendar year and are NOT subject to the “in-network deductible” and coinsurance. This benefit applies to routine
mammograms .
Subsequent non-routine mammograms performed during
the calendar year will be subject to the in-network deductible and coinsurance.
Colonoscopy
Every 5 years ; age 50 & above
Osteoporosis Screening
Females age 60 & above
Prostate Specific Antigen Test (PSA):
Once per calendar year for males age 40 and over & “at
risk” patients
Tetanus-Diptheria Immunization
Once every 10 years
Varicella Immunization (VZV)
“susceptible patients” only- 2 doses
Influenza Immunization
Annual immunizations for ages 50 & above and “at risk”
patients of any age
Adult Preventive Services- applicable for patients age 18 & above (con’t)
The following adult immunizations are covered for one
dose :
Measles, Mumps, Rubella Immunization (MMR)
Pneumococcal Immunization
Human Papillamavirus Vaccine (HPV) Vaccine
(Gardasil)
Zostavax (Shingles vaccine)
MMR: one dose (females ages 18-45)
Pneumocooccal Immunization: one dose (age 65 &
above, “at risk” patient of any age)
HPV: administered in 3 doses, once per lifetime
(females ages 9-25)
Available to members 60 and over obtained from
MD as part of office visit.
Well Child Preventive Care Services
Routine Physical Examinations (including immunizations and lab tests) are covered at 100% and are NOT
subject to the “in-network” deductible & co-insurance for children at the following age intervals.
However, out-of-network preventive services will be subject to the out-of-network deductible and co-insurance.
One visit during period of birth to one month
2 months
4 months
6 months
9 months
12 months
15 months
18 months
Age 2
Age 3
Age 4
Age 5
Age 6
Age 8
Age 10
Age 12
Age 14
Age 16
Age 18
Immunizations included in routine exams at
prescribed age intervals are as follows:
Varicella
Influenza
Hepatitis A
Hepatitis B
Pneumoccal
Inactivated Polio Virus
Measles, Mumps, Rubella
Diphtheria, Petrussis, Tetanus
Haemophilus Type B
Effective 1/1/2013, PPACA provides expanded coverage for
Women’s Preventive Health Services at 100% to include:
Well-woman visits
Gestational diabetes screening for pregnant women
Domestic and interpersonal violence screening and counseling
FDA-approved contraception methods, and contraceptive education and counseling
Breastfeeding support, supplies, and counseling
HPV DNA testing, for women 30 or older
Sexually transmitted infections counseling
HIV screening and counseling for sexually-active women
GENERAL EXCLUSIONS AND LIMITATIONS
The Plan does not cover any expenses incurred for services, supplies, medical care or treatment relating to, arising out
of, or given in connection with, the following:
Acupuncture and treatments by acupuncturists are not covered.
Growth Hormones are not covered
Services or supplies received before an Employee or his/her Dependent becomes covered under this Plan.
Expenses incurred by a Dependent if the Dependent is covered as an Employee for the same services under this
Plan.
Abdominoplastys
Breast reduction surgery, unless it is medically necessary
Chelation therapy, except to treat heavy metal poisoning
Completion of claim forms, or missed appointments
Charges due to cosmetic surgery (except those which are for reconstructive purposes) which improve, alter or enhance appearance, whether or not for psychological or emotional reasons unless it is related to the repair of an
injury or deformation; (surgery must be performed in the same or following calendar year following the accident
or deformation).
Custodial Care. This is care made up of services and supplies that meets one of the following conditions:
Care furnished mainly to train or assist in personal hygiene or other activities of daily living, rather than
to provide medical treatment.
Care that can safely and adequately be provided by persons who do not have the technical skills of a
covered health care professional.
Care that meets one of these conditions is custodial care regardless of any of the following:
Who recommends, provides or directs the care
Where the care is provided
Whether or not the patient or another caregiver can be or is being trained to care for himself or herself.
Ecological or environmental medicine, diagnosis and/or treatment.
Charges for any testing, training, or rehabilitation for educational, developmental or vocational purposes.
Education, training and bed and board while confined in an institution which is mainly a school or other institution for training , a place of rest, a place for the aged or a nursing home. Sensitivity training, educational training
therapy or treatment for an education requirement.
Eyeglasses, contact lenses, eye refractions, unless required due to accidental injury or cataract surgery. Services
for a surgical procedure to correct refraction errors of the eye, including any confinement, treatment, services,
or supplies given in connection with or related to the surgery.
Cochlear implants, unless they are deemed medically necessary.
Herbal medicine, holistic or homeopathic care, including drugs. Charges for nutritional supplements, vitamins or
minerals.
Medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies,
treatments, procedures, drug therapies or devices that, at the time UnitedHealthcare makes a determination regarding coverage in a particular case are determined to be:
▫ Experimental medical, surgical or other experimental healthcare procedures, as determined by UHC,
unless written approval is provided by the Medical Director in advance.
Not approved by the U.S. Food and Drug Administration (“FDA”) to be lawfully marketed for the
proposed use and not identified in the American Hospital Formulary Service, or the United States
▫ subject to review and approval by any institutional review board for the proposed use; or
▫ The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set
forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight; or
▫ Charges for experimental drugs that are not commercially available for purchase and/or are not
approved by the FDA for general use and/or are not being used for the sickness or condition for
which they received FDA approval. However, FDA approval is not required for pharmacological
regimens for the treatment of cancer if such drugs are recognized as acceptable treatment in the
American Hospital Formulary Service Drug Information, or if recommended by review article or
editorial comment in a major peer review or professsional journal.
▫ A service that does not meet the definition of a Covered Health Service
Charges for any care, treatment, services or supplies that are not approved or accepted as essential to the
treatment of any injury or sickness by the AMA, US Surgeon General, the US Public Health or the NIH or
are not recognized by the medical community as potentially safe and efficacious for the care and treatment
of the condition.
If a Covered Person has a “life-threatening illness or condition (one which is likely to cause death within one
year of the request for treatment) , UnitedHealthcare may determine than an Experimental, Investigational
or Unproven Service meets the definition of a Covered Health Service for the Sickness or condition. For this to
take place, UnitedHealthcare must determine that the service uses a specific research protocol that meets standards
equivalent to those defined by the National Institutes of Health.
Services and supplies which the Covered Person is not legally required to pay.
Liposuction
Surgical correction or other treatment of malocclusion
Services or supplies which are not Covered Health Services, including any confinement or treatment given in connection with a service or supply which is not covered under the Plan.
Membership costs for health clubs, weight loss clinics and similar programs. Charges for care, treatment, services
or supplies that are primarily for dietary control, including but not limited to exercise programs whether or not
recommended by an MD.
Nutritional counseling, unless it is prescribed by an MD to treat an underlying medical condition (i.e diabetes, morbid obesity, anorexia nervosa or bulimia).
Weight reduction or control (unless there is a diagnosis of morbid obesity)
Occupational injury or Sickness. An occupational injury or Sickness is an injury or Sickness which is covered under
a workers’ compensation act or similar law.
For persons for whom coverage under a workers’ compensation act or similar law is optional because they
could elect it, or could have elected it for them, occupational injury or Sickness includes any injury or Sick ness that would have been covered under the workers’ compensation act or similar law had that coverage
been elected.
Examinations or treatment ordered by a court in connection with legal proceedings unless such examinations or
treatment otherwise qualify as Covered Services.
Services given by a pastoral counselor
Private duty nursing
Services for, or related to, the removal of an organ or tissue from a person for transplantation into another person
and the cost of securing the services of professional donors, unless the transplant recipient is a Covered Person
under this Plan and is undergoing a covered transplant.
Reversal of sterilization.
Charges made by a Hospital for confinement in a special area of the Hospital which provides non-acute care, by
whatever name called, including but not limited to the type of care given by the facilities listed below.
If that type of facility is otherwise covered under this Plan, then benefits for that covered facility which is
part of a Hospital, as defined, are payable at the coverage level for that facility, not at the coverage level
for a Hospital.
Adult or child day care center
Ambulatory Surgical Center
Birth Center
Half-way house
Hospice
Skilled Nursing Facility
Treatment Center
Vocational rehabilitation center
Any other area of a Hospital which renders services on an inpatient basis for other than acute care of sick,
injured or pregnant persons
Stand-by services required by a Physician
Charges of a Dentist for dental services that are not for the purpose of reconstructive surgical benefits related to
an accident or illness. Care of or treatment to the teeth, gums, or supporting structures such as, but not limited to,
periodontal treatment, endodontic services, extractions, implants or any treatment to improve the ability to chew or
speak (refer to previous section on ‘Covered Services and Supplies’ for more information regarding limited coverage of oral surgery and dental services)
Telephone consultations
Tobacco dependency
Services or supplies received as a result of war declared or undeclared, or international armed conflict. Charges due
to any sickness or injury that results from war, any act of war, any resistance to armed invasion or war related
aggression, any international police action with force of arms by any country or the U.N., and any participation in
the commission of a felony.
Special foods, food supplements, liquid diets, diet plans or any related products.
Wigs (unless required as a result of chemotherapy or radiation therapy), toupees, hair transplants,
hair weaving or any drug if such drug is used in connection with baldness.
Services given by volunteers or persons who do not normally charge for their services.
Services and/or supplies that are covered under the Plan and are dispensed by a physician, dentist or nurse or any
other licensed medical professional or support personnel who normally lives in the covered person’s home or is a
member of their immediate family (including but not limited to parents, children, siblings and grandparents).
Charges for care, treatment, services or supplies that any government or sub-division of government (including
government hospitals) provides and pays for or reimburses, charges incurred by a veteran for a non-service
connected sickness or injury, or charges incurred by retired veterans or dependents confined in a military hospital.
Charges for marriage or sexual counseling including therapy or supplies related to sexual dysfunction or
inadequacies
Charges for items that are generally used for personal comfort and/or useful to the covered person’s household
which include non-hospital beds, air conditioners and humidifiers, air cleaners, filtration units, whirlpools, saunas,
medical equipment used by MDs in their work, vans and van lifts, stair lifts, exercise bicylcles and other types of
exercise equipment.
Hospital charges that are incurred prior to the first Monday of a confinement that begins on a Friday, Saturday, or
Sunday unless such confinement is due to a medical emergency or surgery is performed within 24 hours after such
confinement begins.
Charges incurred outside the U.S. if the covered person traveled to such location to obtain medical services, drugs
or supplies if such services, drugs or supplies are unavailable or illegal in the U.S.
Charges for any procedure or treatment designed to alter physical characteristics of the covered person of the
opposite gender and any other treatment or studies related to sex transformations.
Charges for routine physical examinations solely for insurance, licensing, employment, marriage, school or other
non-preventive purposes and immunizations related to foreign travel.
Charges for domiciliary care, research studies, experimental treatment, rest cures or weight reduction programs.
Charges for any non-medical services and long term rehabilitation services for the treatment of alcoholism, drug
abuse, senility , mental retardation or other mental disorders.
Charges for any non-medical services or treatment of mental retardation, defects or deficiencies, or other mental
health services and developemntal or learning deficiencies.
Charges for long term physical and long term rehabilitation services which do not demonstrate continued
improvement of condition.
Charges for routine foot care (including reduction of nails, callouses and corns), orthopedic shoes or other foot
devices, unless needed due to severe systemic disease.
Charges for any special medical reports not directly related to treatment, or appearances in court or at a hearing.
Charges for Aminocentesis for pregnant covered persons under age 26 unless medically necessary.
Charges for services or supplies furnished by a non-eligible non-licensed professional or institution, which is
defined as a hospital or skilled nursing facility, which is primarily a place of rest, nursing home or custodial care
facility.
Care for conditions that federal, state, or local law requires to be treated in a public facility
Charges for services which are eligible for payment under the provisions of an automobile insurance contract or
pursuant to any federal or state law which mandates indemnification for such services to persons suffering bodily
injury from motor vehicle accidents, where permitted by state law.
Charges that in the absence of insurance, would not be made, or charges for which there is no legal obligation to
pay.
Non-covered services related to Home Health Care & Hospice Care—funeral arrangements, homemaker or
caretaker services, finanacial or legal counseling, services provided by a member of the family or if individual lives
with covered person, transportation expenses and services of a social worker. Coverage of Social Worker would be
excluded if he/she were not part of Home Health Agency. Social Work Services would be part of the hospital bill
if Social Worker is employed by the hospital.
Services which are not medically necessary as determined by the insurance carrier for the diagnosis, care, or
treatment of the physical or mental condition involved even if prescribed by a physician subject to the appeal
process.
Services and supplies that any school system is required to provide under any law.
Kidney dialysis treatment charges that are not covered include expenses for the operation of a dialysis machine
including electricity, water or waste disposal system and services of a person to assist in the use of the dialysis
machine.
Speech therapy to refine a person’s existing speech or to educate an individual whose speech has not yet developed. This exclusion does not apply to charges for speech therapy that is expected to restore speech to a person
who has lost existing speech function (the ability to express thoughts, speak words, and form sentences) as a
result of a disease or injury.
CLAIMS INFORMATION FOR THE UHC PPO PLANS
How to File a Claim
A claim form does not need to be filed when a Network Provider is used. The in-network provider is responsible for
filing the claim
The following steps should be completed when submitting bills for payment for out-of-network services:
Get a claim form from your Employer or UnitedHealthcare (UHC)
Complete the Employee portion of the form.
Have the provider complete the provider portion of the form.
Send the form and bills to the address shown on the form.
Make sure the bills and the form include the following information:
The Employee’s name and social security number
The Employer’s name (i.e NYU Hospitals Center) and contract number (218640)
The patient’s name
The diagnosis
The date the services or supplies were incurred
The specific services or supplies provided
When Claims Must be Filed
You or your covered dependent must provide UHC with written proof of loss within 15 months after the date the
expenses are incurred.
UHC will determine if enough information has been submitted to enable proper consideration of the claim. If not,
more information may be requested.
No benefits are payable for claims submitted after the 15-month period, unless it can be shown that:
It was not reasonably possible to submit the claim during the 15-month period.
Written proof of loss was given to UHC as soon as was reasonably possible.
How and When Claims Are Paid
All payments will be paid to you or your covered dependent as soon as UHC receives satisfactory proof of loss, except in the following cases:
If you, as the covered Employee, have financial responsibility under a court order for a dependent’s medical
care, UHC will make payments directly to the provider of care.
If UHC pays benefits directly to Network Providers
If you, as the covered Employee, request in writing that payments be made directly to a provider (you indicate
this when completing the claim form).
UHC will send an Explanation of Benefits (EOB) to the covered Employee. The EOB will explain how UHC considered each of the charges submitted for payment. If any claims are denied in part, the covered Employee will receive a written explanation. These payments will satisfy UHC’s obligation to the extent of the payment.
In the event of your death, any benefits continued for Covered Dependents will be paid to one of the following:
The surviving spouse or Domestic Partner
A Dependent child who is not a minor, if there is no surviving spouse
A provider of care who charges your covered Dependents for Covered Services and Supplies.
Your covered Dependent’s legal guardian
BENEFIT DETERMINATIONS
Post-Service Claims
Post-Service Claims are those claims that are filed for payment of benefits after medical care has been received.
If your post-service claim is denied, you will receive a written notice from UHC within 30 days of receipt of the claim,
as long as all needed information was provided with the claim. UHC will notify you within this 30-day period if additional information is needed to process the claim, and may request a one time extension not longer than 15 days and
pend your claim until all information is received.
Once notified of the extension, you then have 45 days to provide the necessary information. If all the required information is received within the 45 day timeframe and the claim is denied, UnitedHealthcare will notify you of the denial
within 15 days after the information is received. If you do not provide the needed information within the 45 day period, your claim will be denied.
A denial notice will outline the following: a) the reason for the claim denial (b) will reference the part of the Plan on
which the denial is based (c) will provide the claim appeal procedures.
Pre-Service Claims
Pre-service claims are those claims that require notification or approval prior to receiving medical care. If your claim
was a pre-service claim and was submitted properly with all the needed information, you will receive written notice of
the claim decision from UHC within 15 days of the receipt of the claim. If you filed a pre-service claim improperly,
UHC will notify you of the improper filing and how to correct it within five (5) days after the pre-service claim was
received. If additional information is needed to process the pre-service claim, UHC will notify you of the information
needed within 15 days after the claim was received, and may request a one time extension not longer than 15 days and
pend your claim until all information is received. Once notified of the extension, you then have 45 days to provide this
information. If all of the needed information is received within the 45 day timeframe, UHC will notify you of the determination within 15 days after the information is received.
If you do not provide the required information within the 45 day period, your claim will be denied. The denial notice
will outline the following: a) outline the reason for the claim denial, (b) will reference the part of the Plan on which the
denial is based, and (c) provide the claim appeal procedures.
Urgent Claims that Require Immediate Action
Urgent care claims are those claims that require notification or approval prior to receiving medical care, where a delay in
treatment could seriously jeopardize your life or your health or the ability to regain maximum function or, in the opinion of a physician with knowledge of your medical condition, could cause severe pain.
In these situations:
You will receive notice of the benefit determination in writing or electronically within 72 hours after
UHC receives all necessary information, taking into account the seriousness of your condition.
You will receive notice of denial verbally with a written or electronic confirmation to follow within 3 days.
If you file an urgent care claim improperly, UHC will notify you of the improper filing and how to correct it within 24
hours after the urgent claim was received. If additional information is needed to process the claim, UHC will notify you
of the information needed within 24 hours after the claim was received. You then have 48 hours to provide the requested information.
You will be notified of a determination no later than 48 hours after:
The receipt of the requested information; or
The end of the period within which you were expected to provide the additional information, if the information is not received within that time.
A denial notice will: a) outline the reason for the claim denial (b) reference the part of the Plan on which the denial is
based, and (c) provide the claim appeal procedures.
Concurrent Care Claims
If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and
your request to extend the treatment is an urgent care claim as defined above, your request will be decided within 24
hours, provided your request is made at least 24 hours prior to the end of the approved treatment. UHC will make a
determination on your request for the extended treatment within 24 hours from receipt of your request.
If your request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the
request will be treated as an urgent care claim and decided according to the timeframes described above. If an on-going
course of treatment was previously approved for a specific period of time or number of treatments, and your request to
extend treatment is a non-urgent circumstance, your request will be considered a new claim and decided according to
post-service or pre-service timeframes, whichever applies.
QUESTIONS AND APPEALS REGARDING BENEFIT DETERMINATIONS
Benefit Determinations- What To Do First
If you have a question or concern about a benefit determination, you may contact UHC’s Customer Service Department before requesting a formal appeal. The Customer Service telephone number can be found on your medical ID
card. Customer Service representatives are available during regular business hours, Monday through Friday. If the Customer Service representative cannot resolve the issue to your satisfaction over the phone, you may submit your question
or concern to UHC in writing. However, if you are not satisfied with a benefit determination as described in this
section, you may appeal it (refer to the section on the following page titled “How to Appeal a Claim Decision”),
without first contacting Customer Service.
If you decide to first contact Customer Service and later wish to send your appeal in writing, a UHC Customer Service
Representative can provide you with the appropriate address.
Your Rights When Appealing A Claim Denial
If you or your covered dependent’s claim(s) for benefits is denied , in whole or in part, you or your covered dependent
have the right to :
An explanation of why the claim was denied, in whole or in part
Obtain copies of documents relating to the decision, without charge
Appeal any claim denial, all within certain time schedules described in this section of the Summary Plan Description.
How to Appeal a Claim Decision
If you disagree with a pre-service or post-service claim determination after following the steps outlined in the section
above, you can contact UHC in writing to formally request an appeal. Your request for an appeal should include:
Your name (or covered dependent’s name if they are the patient) and the identification number from the ID
card;
The date(s) of medical service(s) in question;
The provider’s name
The reason you believe the claim should be paid; and
Any documentation or other written information to support your request for claim payment.
Your first level appeal review must be submitted to UHC within 180 days after you receive the claim denial.
The Appeal Process
A qualified individual who was not involved in the decision being appealed will be appointed to decide the appeal.
If your appeal is related to clinical matters, the review will be done in consultation with a health care professional with
the appropriate expertise in the field who was not involved in the prior determination. UHC may consult with, or
seek the participation of, medical experts as part of the appeal resolution process. Your consent is needed for such a
consultation and sharing of pertinent information to take place. Upon request and free of charge, you have the right to
reasonable access to and copies of , all documents, records and other information relevant to your claim for benefits.
APPEALS DETERMINATIONS
Pre-Service Claims
For appeals of pre-service claims (as defined in the ‘Benefit Determinations’ section ), the first level appeal will be conducted and you will be notified by UnitedHealthcare of the decision within 15 days from receipt of a request for appeal
of a denied claim. If you are not satisfied with UHC’s first level appeal decision, you have the right to request a second
level appeal from UHC’s. Your second level appeal request must be submitted to UHC in writing within 60 days from
receipt of the first level appeal decision.
The second level appeal will be conducted and you will be notified by UHC of the decision within 15 days
from receipt of a request for review of the first level appeal decision.
Post-Service Claims
For appeals of post-service claims (as defined in the Benefit Determinations section on pages 66-67), the first level
appeal will be conducted and you will be notified by UHC of the decision within 30 days from receipt of the request for
appeal of a denied claim. If you are not satisfied with the first level appeal decision by UHC, you have the right to
request a second level of appeal from UHC. Your second level appeal request must be submitted to UHC in writing
within 60 days from receipt of the first level appeal decision.
The second level appeal will be conducted and you will be notified by UHC of the decision within 30 days
from receipt of a request for review of the first level appeal decision.
Pre-Service and Post-Service Claims
For pre-service and post-service claim appeals, NYUHC has delegated to UHC the exclusive right to interpret and
administer the provisions of the Plan. UHC’s decisions are conclusive and binding.
Please also note that UHC’s decision is based only on whether or not benefits are available under the Plan for the proposed treatment or procedure. The determination as to whether the pending health service is necessary or appropriate
is between you and your Physician.
Urgent Claim Appeals that Require Immediate Action
Your appeal may require immediate action if a delay in treatment could significantly increase the risk to your health or
the ability to regain maximum function or cause severe pain. In these urgent situations, the appeal does not need to be
submitted in writing. You or your Physician should contact UHC as soon as possible. UHC will provide you with a
written or electronic determination within 72 hours following receipt by UHC of your request for review of the determination, taking into account the seriousness of the your condition.
Voluntary External Review Program
If a final determination to deny benefits is made, you may choose to participate in UHC’s voluntary external review
program. This program only applies if the decision is based on either of the following:
Clinical reasons
The exclusion for Experimental, Investigational or Unproven Services
The external review program is not available if the coverage determinations are based on explicit Benefit exclusions or
defined Benefit limits. For more information on the Voluntary External Review Program, contact UHC at the telephone number found on your ID card.
LEGAL ACTION
You cannot bring any legal action against NYUHC or UnitedHealthcare Service LLC (UHC) for any other reason
unless you first complete all the steps in the appeal process described in this Summary Plan Description. After completing that process, if you want to bring a legal action against NYUHC or UHC, you must do so within three years of
the date you are notified of the final decision on the appeal or you lose any right to bring such an action against
NYUHC or UHC.
If you or your covered dependent want to bring a legal action against the Plan Sponsor (NYU Hospitals Center), or
UHC the legal action must be taken within three (3) years from the expiration of the time period in which a request
for coverage must be submitted.
If legal action is not taken within this period, the right to bring such action against NYUHC or UHC will be lost.
COORDINATION OF BENEFITS UNDER THE UHC PPO PLANS
If you and/or your eligible dependents are enrolled under the NYUHC Health & Welfare Plan (“the Plan”) and are
also covered under another group medical plan (i.e. covered through Medicare, covered through your spouse’s
employer, or coverage provided through auto insurance ), the two plans may coordinate their benefit payments such
that the combined payments of both plans do not exceed the actual expenses incurred for that plan year. It is this
method of paying benefits when more than one plan covers you or an eligible dependent is referred to as
“Coordination of Benefits”.
One of the plans involved will pay the benefits first- that plan is Primary. Other plans will pay benefits nextthose plans are Secondary. The rules governing the Coordination of Benefits provision determine which plan is
Primary and which plan is Secondary when you and/or your eligible dependents are covered by more than one
medical plan.
Definitions of Commonly Used Terms Regarding Coordination of Benefits
“Other Plans” are any of the following types of plans which provide health benefits or services for medical
care or treatment:
Group policies or plans, whether fully insured or self-insured. This does not include school accidenttype coverage.
Group coverage through an EPO or HMO and other prepayment, group practice and individual practice plans.
Group-type plans obtained and maintained only because of membership in or connection with a particular
organization or group.
Government or tax supported programs. This does not include Medicare or Medicaid.
No-Fault motor vehicle laws.
A “Primary Plan” is a plan that will pay benefits first. Benefits under that plan will not be reduced due to benefits payable under Other Plans.
“Secondary Plans” - benefits under a plan that is “Secondary” may be reduced due to benefits payable under
Other Plans that are Primary.
“Allowable Expenses” means the necessary, reasonable and customary expense for health care when the
expense is covered in whole or part under at least one of the plans.
The difference between the cost of a private Hospital room and the cost of a semi-private Hospital room is not considered an “Allowable Expense” .
When a plan provides benefits in the form of services, instead of a cash payment, the reasonable cash value of each
service rendered will be considered both an Allowable Expense and a benefit paid.
Coordination of
Plan”)
Benefits Payments Under NYUHC Health & Welfare Plan (“the
If the NYUHC Plan is the Primary payer- that is, the plan that pays benefits first-it pays expenses as if no
other insurance plan was involved.
When NYUHC the Plan is Secondary , benefits paid under the Plan are reduced so that the total benefits
paid or provided by all plans considered during a Calendar year do not exceed total Allowable Expenses of
the Primary Plan. This means if the primary plan’s allowable expenses are higher than the allowable
expenses under the NYUHC Plan, then the NYUHC Plan will use the Primary Plan’s higher allowable expenses as a basis for determining benefits. The NYUHC Plan will not reduce the allowable expenses incurred
under the Primary Plan for coordination of benefit purposes.
The amount by which the Plan’s benefits have been reduced shall be used by the Plan to pay Allowable
Expenses not otherwise paid, which were incurred during the Calendar Year by the person making the
claim for benefits. As each claim is submitted, the Plan determines its obligation to pay for Allowable
Expenses based on all claims which were submitted up to that point in time during the Calendar Year.
The benefits of this Plan will only be reduced when the sum of the benefits that would be payable for
the Allowable Expenses under the Other Plans (in the absence of similar Coordination of Benefit provisions), exceed those Allowable Expenses in a Calendar Year -whether or not a claim is made. When
benefits of this Plan are reduced as described, each benefit is reduced “proportionally”. It is then charged
against any applicable benefit limit of this Plan.
Rules Governing Coordination of Benefits
When you and/or your eligible dependents are covered by more than one medical plan, the benefit payments will follow the rules in the order described below:
A plan with no coordination of benefits provision will be considered the Primary plan.
The plan which covers the person other than as a dependent is considered the Primary plan. The plan w h i c h
covers the person as a dependent is considered the Secondary Plan.
For example, the NYUHC plan is always the Primary Plan for you, as an employee of NYUHC enrolled in the
Plan. However, the NYUHC plan will be secondary for your spouse if your spouse is covered under this plan as
well as their own plan through his/her employer. Similarly, your spouse’s plan will always be the Primary Plan
for your spouse, but it will be Secondary for you if you are covered under your spouse’s plan and under this
plan.
The plan covering the person as a dependent or employee is considered ‘Primary’ IF the person is age 65 and
older, enrolled in Medicare and also enrolled in an active group health plan.
When the NYUHC Health & Welfare Plan (“the Plan”) and another plan cover the same child as a dependent
of parents who are not separated or divorced, the benefits of the plan of the parent whose birthday falls earlier
in a year is Primary. The plan of the parent whose birthday falls later in that year (the year of birth is ignored) is
Secondary. This rule is referred to as the “Birthday Rule”.
If both parents happen to have the same birthday, the benefits of the plan which covered one parent
for a longer period of time is considered the Primary Plan. The plan that covered the other parent for
the shorter period of time is considered the Secondary Plan.
If the other plan does not have a birthday rule, but instead has a rule based on the gender of the parent AND
as a result, the plans do not agree on the order of benefit plan payments, the rule in the other plan will determine the order of benefits.
If two or more plans cover a dependent child of divorced or separated parents, benefits for the child are
determined in the following order:
The Primary Plan will be the plan of the parent who has custody of the child.
The Secondary Plan will be the plan of the spouse of the parent who has custody of the child
Finally, the plan of the parent not having custody of the child will be determined last.
Please bear in mind that if the specific terms of a court decree state that one of the parents is responsible for
the health care expense of the child , AND the entity that would be responsible to provide plan benefits to that
parent has actual knowledge of those terms, the benefits of that parent’s plan is considered to be the Primary
Plan. The plan of the other parent shall be considered the Secondary Plan.
Please be advised that this rule does not apply with respect to any claim for which any benefits are actually
paid or provided before the entity has that actual knowledge.
If the specific terms of a court decree state that the parents shall share joint custody, without stating that one of
the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the
order of benefit determination rules that apply to dependents of parents who are not separated or divorced (refer
to the “Birthday Rule” provisions).
The plan which covers a person as an employee who is neither laid off nor retired is considered the Primary
Plan. The plan which covers a person as a laid off or retired employee is considered the Secondary Plan.
The same rule applies if a person is a dependent of a person covered as a retiree or an employee. If the
other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this
rule is ignored.
If none of the rules determines the order of benefits, the benefits of the plan which covered an employee,
member or subscriber for the longer period is considered the Primary Plan. The plan that covered the person
for a shorter period of time would be considered the Secondary Plan.
Coordination of Benefits Involving Medicare and Government Plans
When NYUHC Health & Welfare Plan (“the Plan”) Pays Primary to Medicare
The Plan pays primary to Medicare for Covered Persons who are Medicare eligible if:
▪ Eligibility for Medicare is due to age 65 and the employee has “current employment status” with NYUHC as
defined by federal law and determined by NYUHC and he/she and dependents are enrolled or eligible for the Plan.
Eligibility for Medicare is due to disability and the employee has “current employment status” with NYUHC
as defined by federal law and determined by NYUHC and he/she and dependents are enrolled or eligible for the
Plan,
Eligibility for Medicare is due to End Stage Renal Disease (ESRD) under the conditions and for the time periods
specified by federal law.
When Medicare Pays Primary to NYUHC Health & Welfare Plan (“the Plan”)
Medicare pays benefits on your behalf first before this Plan in the following instances:
Eligibility is due to disability or over age 65 and the Employee and dependent do NOT have “current employment status” with NYUHC as defined by federal law and determined by NYUHC.
▪ Eligibility for Medicare is due to End Stage Renal Disease (ESRD), but only after conditions and the time periods
specified by federal law.
IMPORTANT! - MEDICARE ENROLLMENT INFORMATION
When this Plan pays benefits first, without regard to Medicare, and you want Medicare to
pay after this Plan, you must enroll for Medicare Parts A and B.
Government Plans (other than Medicare and Medicaid)
A Government Plan is any Plan, program, or coverage-other than Medicare or Medicaid- which is established under the
laws or regulations of any government, or in which any government participates other than as an employer.
If you and or your covered spouse are also covered under a Government Plan, the NYUHC Health & Welfare Plan
Plan does not cover any services or supplies to the extent that those services or supplies, or benefits for them, are available to you under the Government Plan. This provision does not apply to any Government Plan which by law requires
this Plan to pay primary.
Right to Exchange Information
In order to coordinate benefit payments, UHC will need access to certain information. It may need to obtain information necessary for claims review/benefit payments from another organization or person and will need to provide necessary claims information to an organization or person(s). UHC is not required to inform, or obtain your consent of anyone to do this (for more information, refer to section on ‘Privacy Practices Regarding Your Health Information’ ) .
You will need to furnish UHC with any information requested about other plans. If you are unable to furnish UHC
with all of the information UHC requires, UHC has the right to obtain this information from any source. Furthermore,
if any other organization or person needs information to apply its Coordination of Benefits provision, UHC has the
right to provide that organization or person with such information. Information can be given or obtained without the
consent of any person to do this.
Facility of Payment
It is possible for benefits to be paid first under the wrong plan. UHC may pay the plan or organization or person for
the amount of benefits that it should have otherwise paid that organization or person. That amount will be treated as if
it was paid under this Plan. The Employer or Plan will not have to pay that amount again. .
Right of Recovery
UHC may pay benefits that should be paid by another plan, organization or person. NYUHC or the Plan may recover
the amount paid from the other plan, organization, or person. Also, NYUHC or the Plan has the right to recover
excess payments in cases where benefits paid were in excess of what should have been paid under the Plan.
Recovery Provisions
Refund of Overpayments
If benefits are paid under this Plan on behalf of any eligible expenses incurred by you or your covered dependent(s),
you, your covered dependent or any other person or organization that was paid must make a refund to the Plan if:
All or some of the expenses were not paid by you or your covered dependent or did not legally have to be
paid by you or your covered dependent.
All or some of the payment made under this Plan exceeded the benefits under this Plan.
The refund equals the amount of benefits paid in excess of the amount that should have been paid under this Plan.
If you were paid benefits in excess of what should have been paid under the Plan, and you do not promptly refund the
full amount, the amount of any future benefits that are payable to you under this Plan may be reduced. The reductions will equal the amount of the required refund. The Plan may have other rights in addition to the right to reduce
future benefits.
If the refund is due from another person or organization, you may agree to help NYUHC get the refund when requested. However, you would not be held responsible to refund excess benefit payments on behalf of any other person, provider or organization who were paid benefits in excess of what they should have received. The Plan will
recover the excess amount paid from the other person or organization.
Subrogation and Reimbursement
Subrogation is defined as the substitution of one person or entity in the place of another with reference to a lawful
claim, demand or right.
Immediately upon paying or providing any benefit, the Plan will be subrogated to and will succeed all rights of recovery,
under any legal theory of any type for the reasonable value of any services and benefits the Plan provided to Covered
Persons from any or all of the following listed below.
In addition to any subrogation rights and in consideration of the coverage provided by the Plan, the Plan will also have
the independent right to be reimbursed by covered individuals for the reasonable value of any or all of the following
listed below:
Third parties, including any person alleged to have caused a covered individual under the Plan to suffer injuries
or damages.
A Covered Person’s employer.
Any person or entity who is or may be obligated to provide benefits or payments to a Covered Person, including
benefits or payments for underinsured or uninsured motorist protection, no-fault or traditional auto insurance,
medical payment coverage (auto, homeowners or otherwise), workers’ compensation coverage, other insurance
carriers or third party administrators.
Any person or entity who is liable for payment to a Covered Person or any equitable or legal liability theory.
These third parties and persons or entities are collectively referred to as “Third Parties”. Covered Persons agree as
follows:
To cooperate with the Plan in a timely manner in protecting its legal and equitable rights to subrogation and reim
bursement, including, but not limited to:
providing any relevant information requested by the Plan;
Signing and/or delivering such documents as the Plan or its agents reasonably request to secure the subrogation
and reimbursement claim;
responding to requests for information about any accident or injuries;
Appearing at depositions and in court; and
Obtaining the consent of the Plan or its agents before releasing any party from liability or payment of medical
expenses.
▪ That failure to cooperate in this manner will be considered a breach of contract, and may result in the termination of
health benefits and/or the institution of legal action against a Covered Person.
That the Plan has the sole authority and discretion to resolve all disputes regarding the interpretation of the language
stated here.
That no court costs or attorneys’ fees may be deducted from the Plan’s recovery without the Plan’s express written
consent. Any so-called “Fund Doctrine” or “Common Fund Doctrine” shall not defeat this right, and the Plan
is not required to participate in or pay court costs or attorneys’ fees to the attorney hired by a Covered Person to
pursue his or her damage/personal injury claim.
That regardless of whether a Covered Person has been fully compensated or made whole, the Plan may collect
from Covered Persons the proceeds of any full or partial recovery that a covered Person or his or her legal
representative obtain, whether in the form of a settlement (either before or after any determination of liability) or
judgment.
The proceeds available for collection will include, but not be limited to any and all amounts earmarked as noneconomic damage settlement or judgment.
That benefits paid by the Plan may also be considered to be benefits advanced.
That Covered Persons agree that if they receive any payment from any potentially responsible party as a result of an
injury or illness, whether by settlement (either before or after any determination of liability), or judgment, the Cov
ered Person will serve as a constructive trustee over the funds, and failure to hold such funds in trust will be
deemed as a breach of his or her duties hereunder. That Covered Persons or an authorized agent, such as the Cov
ered Person’s attorney, must hold any funds received from any potentially responsible party that are due and owed
to the Plan, as stated herein, separately and alone, and failure to hold funds as such will be deemed as a breach of
contract, and may result in the termination of health benefits or legal action against the Covered Person.
That the Plan shall be entitled to recover reasonable attorney fees from the Covered Person incurred in collecting from the Covered Person any funds held by the Covered Person, recovered from any Third Party.
That the Plan may set off from any future benefits otherwise allowed by the Plan, the value of benefits paid or
advanced under this section to the extent not recovered by the Plan.
That a Covered Person will neither accept any settlement that does not fully compensate or reimburse the Plan
without its written approval, nor will a Covered Person do anything to prejudice the Plan’s rights under this section.
That Covered Person will assign to the Plan all rights of recovery against Third Parties, to the extent of the reason
able value of services and benefits the Plan provided, plus reasonable costs of collection.
That the Plan Sponsor’s rights will not be reduced due to the Covered Person’s own negligence.
That the Plan’s rights will be considered as the first priority claim against Third Parties, including for whom the
Covered Person is seeking recovery, to be paid before any other of the Covered Person’s claims are paid.
That the Plan may, at its discretion take necessary and appropriate action to preserve its rights under these subroga
tion provisions, including filing suit in a Covered Person’s name, which does not obligate the Plan in any way to pay
a Covered Person part of any recovery the Plan might obtain.
That the Plan shall not be obligated in any way to pursue this right independently or on a Covered Per son’s behalf.
That if the injury or condition giving rise to subrogation or reimbursement involves a minor child, this
section applies to the parents or guardian of the minor child.
That if the injury or condition giving rise to subrogation or reimbursement involves the wrongful death
of a Plan beneficiary, this section applies to the personal representative of the deceased Plan beneficiary.
CONTINUATION OF HEALTH COVERAGE
UNDER THE UHC PPO PLANS
If your coverage under the plan should terminate due to any of the following ‘qualifying events’, you and your eligible
dependents have the option to continue health coverage under the Consolidated Omnibus Budget Reconciliation
Act of 1985 (COBRA):
termination of your employment for any reason (except for gross misconduct)
reduction in scheduled work hours that ends your eligibility
divorce or legal separation from your spouse or termination of your domestic partner relationship
your dependent child no longer qualifies as an eligible dependent child under the Plan ( child reaches age 26)
you become enrolled in Medicare
your death
The type of coverage being offered for continuation under COBRA will be the same type of coverage offered to active
employees by NYUHC and if there are changes made to those coverages offered to active Employees, those coverage
changes will also apply to COBRA recipients.
For further information, please refer to the sections of this Summary Plan Description titled ‘When Health
Coverage Ends’ on page and ‘Continuation of Health Coverage Under COBRA’ .
CONVERSION COVERAGE
When your COBRA coverage under the UnitedHealthcare (UHC) PPO Plan ends, you also have the option to purchase
individual health insurance (referred to as “Conversion Coverage”).
Proof of insurability is not required to purchase Conversion Coverage. However, if the benefits under Conversion
Coverage are greater than those offered under the Plan, you and/or your eligible covered dependents will be asked to
provide proof of insurability for the greater benefits being offered under Conversion Coverage.
If you have covered dependents when COBRA coverage under the Plan ends, the Conversion coverage will provide
coverage for you and all your eligible covered dependents on the day such coverage stops. You must apply for Conversion Coverage on the same basis as the coverage you had under the UnitedHealthcare PPO plans offered by NYUHC.
You cannot apply for single Conversion Coverage unless you are enrolled for ‘Employee Only’ coverage under this
Plan.
An individual policy will be issued if the person converting (either you or your covered dependent) is eligible and lives
in one of the following states: Georgia, Maine, Minnesota, Nevada, New Hampshire, New Mexico, New York, Ohio,
Oregon, Puerto Rico, South Dakota, Vermont, Virginia.
If the person converting lives in a state or jurisdiction of the United States not listed above and is eligible, Conversion
Coverage will be provided through The Group Conversion Trust. The person will receive a Certificate of Insurance
instead of an individual policy.
Please refer to the section on ‘Conversion Coverage for Medicare Eligibles’ if you or your covered dependent is
Medicare eligible.
CONDITIONS FOR CONVERSION
For Covered Employees
You must have been continuously enrolled for COBRA coverage offered by NYUHC and your COBRA coverage
must have ended for either one of the following reasons:
Your COBRA period expires
You failed to pay COBRA premiums
Important Note: If your coverage under the NYUHC Plan stops because the plan is terminated, you will not
have the right to purchase Conversion Coverage.
For Covered Dependents
▪ In the event of your death, your spouse or any guardian of your covered dependent child(ren) may purchase
conversion Coverage for your covered Dependents.
If your marriage is dissolved, your former spouse may purchase Conversion Coverage. The purchase of Conver sion Coverage can happen at either of the following times:
When the marriage is dissolved.
At the end of any period of continuation of coverage under COBRA offered by NYUHC ; but only if the Plan
is in force on that date.
Any of your covered Dependents may purchase Conversion Coverage if one of the following is true:
Your Dependent child(ren) are no longer eligible for coverage.
HOW TO APPLY FOR CONVERSION COVERAGE
To apply for Conversion Coverage, you must first obtain an application form from UnitedHealthcare.
You are required to complete and submit the application within 31 days after your COBRA coverage under NYUHC.
The first premium must be paid before Conversion Coverage can be put in force.
Conversion coverage will be effective on the date that the COBRA coverage ends. In some cases, a covered Employee
can choose COBRA coverage after employment ends. In some cases, a covered Employee’s Dependents can choose
COBRA coverage after the covered Employee’s death. In these cases, Conversion Coverage will go into effect when
the continued coverage under COBRA stops, but only if this Plan is in force on that date.
In the event of your death within the 31-day conversion period, your spouse or any guardian of your covered Dependents may apply for Conversion Coverage for your covered Dependents.
Limitations
Conversion Coverage may have greatly reduced benefits at a much higher cost. In most cases, the benefits will be
limited to Hospital and surgical benefits only.
The benefit amounts for Conversion Coverage will be governed by the following:
The rules of the insurance company (UnitedHealthcare)
The laws of the state or jurisdiction where the person lives when he or she applies.
A copy of the individual policy or Certificate of Insurance is on file with the state insurance authority, where required. A Copy may also be obtained from UnitedHealthcare.
UnitedHealthcare might limit the benefits of, or refuse to issue, Conversion Coverage because you or your dependent has other health coverage. The rules will be communicated to each person when they apply.
CONVERSION COVERAGE FOR MEDICARE ELIGIBLES
If you or your covered dependent is Medicare eligible and lives in one of the following states– you are NOT eligible
for Conversion Coverage: Georgia, Maine, Minnesota, Nevada, New Hampshire, New Mexico, New York, Ohio,
Oregon, Puerto Rico, South Dakota, Vermont, Virginia.
If you or your covered dependent is Medicare eligible and lives in any other state or jurisdiction of the United States,
you will be offered Conversion Coverage through The Group Conversion Trust.
GLOSSARY FOR UNITEDHEALTHCARE PPO PLANS
These definitions apply when the following terms are used with respect to the UnitedHealthcare (UHC) PPO plans:
Ambulatory Surgical Center
A specialized facility which is established, equipped, operated and staffed primarily for the purpose of performing surgical procedures and which fully meets one of the following two tests:
It is licensed as an Ambulatory Surgical Center by the regulatory authority having responsibility for the licensing under the laws of the jurisdiction in which it is located.
Where licensing is not required, it meets all of the following requirements:
It is operated under the supervision of a licensed doctor of medicine (M.D.) or doctor of osteopathy
(D.O.) who is devoting full time to supervision and permits a surgical procedure to be performed only by
a duly qualified Physician who, at the time the procedure is performed, is privileged to perform the procedure in at least one Hospital in the area.
It requires in all cases, except those requiring only local infiltration anesthetics, that a licensed anesthesiologist administer the anesthetic or supervise an anesthetist who is administering the anesthetic and that
the anesthesiologist or anesthetist remain present throughout the surgical procedure.
It provides at least one operating room and at least one post-anesthesia recovery room.
It is equipped to perform diagnostic X-ray and laboratory examinations or has an arrangement to obtain
these services.
It has trained personnel and necessary equipment to handle emergency situations.
It has immediate access to a blood bank or blood supplies.
It provides the full-time services of one or more registered graduate nurses (R.N.) for patient care in the
operating rooms and in the post anesthesia recovery room.
It maintains an adequate medical record for each patient, the record to contain an admitting diagnosis
including, for all patients except those undergoing a procedure under local anesthesia, a preoperative examination report, medical history and laboratory tests and/or X-rays, an operative report and a discharge
summary.
An Ambulatory Surgical Center which is part of a Hospital, as defined here, will be considered an Ambulatory Surgical
Center for the purposes of this Plan.
Birth Center
A specialized facility which is primarily a place for delivery of children following a normal uncomplicated pregnancy
and which fully meets one of the following two tests:
It is licensed by the regulatory authority having responsibility for the licensing under the laws of the jurisdiction in which it is located:
It meets all of the following requirements:
It is operated and equipped in accordance with any applicable state law.
It is equipped to perform routine diagnostic and laboratory examinations such as hematocrit and urinalysis for glucose, protein, bacteria and specific gravity.
It has availability to handle foreseeable emergencies, trained personnel and necessary equipment, including but
not limited to oxygen, positive pressure mask, suction, intravenous equipment, equipment for maintaining
infant temperature and ventilation, and blood expanders.
It is operated under the full-time supervision of a licensed doctor of medicine (M.D.), doctor of osteopathy
(D.O.) or registered graduate nurse (R.N).
It maintains a written agreement with at least one Hospital in the area for immediate acceptance of patients
who develop complications.
It maintains an adequate medical record for each patient, the record to contain prenatal history, prenatal examination, any laboratory or diagnostic tests and a postpartum summary.
It is expected to discharge or transfer patients within 24 hours following delivery.
A Birth Center which is part of a Hospital, as defined here, will be considered a Birth Center for the purposes of this
Plan.
Calendar Year
A period of one year beginning with January 1.
Comprehensive Outpatient Rehabilitation Facility
A facility which is primarily engaged in providing diagnostic, therapeutic and restorative services to outpatients for
the rehabilitation of injured or sick persons and which fully meets one of the following two tests.
It is approved by Medicare as a Comprehensive Outpatient Rehabilitation Facility.
It meets all of the following tests:
It provides at least the following comprehensive outpatient rehabilitation services:
Services of Physicians who are available at the facility on a full or part-time basis.
Physical therapy
Social or psychological services
It has policies established by a group of professional personnel (associated with the facility) including one or
more Physicians to govern the comprehensive outpatient rehabilitation services it furnishes, and provides
for the carrying out of such policies by a full or part-time Physician.
It has a requirement that every patient must be under the care of a Physician
It is established and operated in accordance with the applicable licensing and other laws.
Covered Health Service(s)
Covered Health Services are those health services, supplies or equipment provided for the purpose of preventing,
diagnosing or treating sickness, injury, mental illness, substance abuse, or symptoms as described in this Summary
Plan Description. Covered Health Services must be provided:
When the Plan is in effect;
Prior to the date that any of the individual termination conditions set forth in this Summary Plan Description ; and
Only when the person who receives services is a Covered Person and meets all eligibility requirements specified in the Plan.
A Covered Health Service must meet each of the following criteria:
It is supported by national medical standards of practice
It is consistent with conclusions of prevailing medical research that demonstrates that the health service
has a beneficial effect on health outcomes and are based on trials that meet the following designs:
Well-conducted randomized controlled trials (Two or more treatments are compared to each other,
and the patient is not allowed to choose which treatment is received).
Well-conducted cohort studies (Patients who receive study treatment are compared to a group of
patients who receive standard therapy. The comparison group must be nearly identical to the study
treatment group).
It is the most cost-effective method and yields a similar outcome to other available alternatives.
It is a health service or supply that is described in this section, and which is not excluded under General
Exclusions and Limitations
Decisions about whether to cover new technologies, procedures and treatments will be consistent with conclusions
or prevailing medical research, based on well-conducted randomized trials or cohort studies, as described.
Covered Family Members or Covered Person
The Employee and the Employee’s wife or husband , domestic partner and/or dependent children who are covered
under this Plan.
Designated Transplant Facility
A facility designated by UnitedHealthcare to render necessary Covered Services and Supplies for Qualified Procedures under this Plan.
Emergency Care
Medical care and treatment provided after the sudden onset of a medical condition manifesting itself by acute symptoms, including severe pain, which are severe enough that the lack of immediate medical attention could reasonably
be expected to result in any of the following:
The patient’s health would be placed in serious jeopardy.
Bodily function would be seriously impaired.
There would be serious dysfunction of a bodily organ or part.
In addition, Emergency Care includes immediate Mental Disorder Treatment when the lack of the treatment could
reasonably be expected to result in the patient harming himself or herself and/or other persons.
Employee
A person on the payroll of the Employer and regularly employed by the Employer as defined by the eligibility criteria outlined on page 7 of this Summary Plan Description .
Experimental, Investigational or Unproven Services
Medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time UnitedHealthcare makes a determination regarding
coverage in a particular case are determined to be:
not approved by the U.S. Food and Drug Administration (“FDA”) to be lawfully marketed for the
proposed use and not identified in the American Hospital Formulary Service, or the United States Pharmacopoeia Dispensing Information, as appropriate for the proposed use; or
subject to review and approval by any institutional review board for the proposed use; or
the subject of an ongoing clinical trail that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in
the FDA regulations, regardless of whether the trial is actually subject to FDA oversight; or
not demonstrated through prevailing peer-reviewed medical literature to be safe and effective for treating
or diagnosing the condition or illness for which its use is proposed.
UnitedHealthcare in its judgement, may deem an Experimental, Investigational or Unproven Service covered under
this plan for treating a life threatening* sickness or condition if it is determined by UnitedHealthcare that the
Experimental, Investigational or Unproven Service at the time of the determination:
is proved to be safe with promising efficacy; and
is provided in a clinically controlled research setting, and
uses a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health.
*For the purpose of this definition, the term “life threatening” is used to describe sickness or conditions which are
more likely than not to cause death within one year of the date of the request for treatment.
Home Health Care Agency
An agency or organization which provides a program of home health care and which meets one of the following
three tests:
It is approved under Medicare
It is established and operated in accordance with the applicable licensing and other laws.
It meets all of the following tests:
It has the primary purpose of providing a home health care delivery system bringing supportive services to
the home.
It has a full-time administrator
It maintains written records of services provided to the patient.
Its staff includes at least one registered graduate nurse (R.N.) or it has nursing care by a registered graduate
nurse (R.N.) available
Its employees are bonded and it maintains malpractice insurance.
Hospice
An agency that provides counseling and incidental services for a terminally ill individual. Room and Board may be
provided. The agency must meet one of the following three tests:
•
It is approved by Medicare as a Hospice
•
It is licensed in accordance with any applicable state laws.
•
It meets the following criteria:
It provides 24 hour-a-day, 7 day-a-week service
It is under the direct supervision of a duly qualified Physician
○
It has a nurse coordinator who is a registered graduate nurse with four years of full-time clinical
experience. Two of these years must involve caring for terminally ill patients.
The main purpose of the agency is to provide Hospice services.
It has a full-time administrator.
It maintains written records of services given to the patient.
It maintains malpractice insurance coverage
A Hospice which is part of a Hospital will be considered a Hospice for the purposes of this Plan.
Hospital
An institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an
inpatient basis at the patient’s expense and which fully meets one of the following three tests:
It is accredited as a Hospital by the Joint Commission on Accreditation of Healthcare Organizations.
It is approved by Medicare as a Hospital
It meets all of the following tests:
It maintains on the premises diagnostic and therapeutic facilities for surgical and medical diagnosis and
treatment of sick and injured persons by or under the supervision of a staff of duly qualified Physicians
It continuously provides on the premises 24-hour-a-day nursing service by or under the supervision of
registered graduate nurses
It is operated continuously with organized facilities for operative surgery on the premises
Licensed Counselor
A person who specializes in Mental Disorder Treatment and is licensed as a Licensed Professional Counselor (LPC)
or Licensed Clinical Social Worker (LCSW) by the appropriate authority.
Medically Necessary or Medical Necessity
Health care services and supplies which are determined by UnitedHealthcare to be medically appropriate, and
(1) necessary to meet the basic health needs of the Covered Person; and
(2) rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the service
or supply; and
(3) consistent in type, frequency and duration of treatment with scientifically based guidelines of national
medical research, or health care coverage organizations or governmental agencies that are accepted by
UnitedHealthcare and;
(4) consistent with the diagnosis of the condition; and
(5) required for reasons other than the convenience of the Covered Person or his or her Physician; and
(6) demonstrated through prevailing peer-reviewed medical literature to be either:
a. safe and effective for treating or diagnosing the condition or sickness for which their use is
proposed, or,
b. safe with promising efficacy
(i) for treating a life threatening* sickness or condition, and
(ii) in a clinically controlled research setting; and
(iii) using a specific research protocol that meets standards equivalent to those defined by the
National Institutes of Health.
*For the purposes of this definition, the term “life threatening” is used to describe sickness or conditions which are more likely than not to cause death within one year of the date of the request for treatment.
The fact that a Physician has performed or prescribed a procedure or treatment or the fact that it may
be the only treatment for a particular injury, physical ailment, mental illness or pregnancy does not
mean that it is a Medically Necessary service or supply as defined here. The definition of Medically
Necessary used in this Summary Plan Description relates only to coverage and differs from the way in
which a Physician engaged in the practice of medicine may define medically necessary.
Medicare
The Health Insurance For the Aged and Disabled program under Title XVII of the Social Security Act.
Mental Disorder Treatment
Mental Disorder Treatment is treatment for both of the following:
Any sickness which is identified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including a psychological and/or physiological dependence or addiction to alcohol or psychiatric drugs or medications, regardless of any underlying physical or organic cause, and
Any sickness where the treatment is primarily the use of psychotherapy or other psychotherapist methods.
All inpatient services, including Room and Board, given by a mental health facility or area of a Hospital which provides mental health or substance abuse treatment for a sickness identified in the DSM, are considered Mental Disorder Treatment, except in the case of multiple diagnoses. If there are multiple diagnoses, only the treatment for the
sickness which is identified in the DSM is considered Mental Disorder Treatment.
Detoxification services prior to and independent of a course of psychotherapy or substance abuse treatment is not
considered Mental Disorder Treatment. Prescription Drugs are not considered Mental Disorder Treatment.
Network Provider (also referred to as ‘In-Network’ provider)
A provider which participates in the UnitedHealthcare network. There are Top Tier and Middle Tier providers in the
network. “Top Tier” providers are generally defined as a select group of NYULMC/HJD health providers that
have agreed to participate in the Top Tier Network AND are also in the UnitedHealthcare Network. Other participating providers are in the UnitedHealthcare General Network (“Middle Tier” providers), but are not part of the
NYULMC/HJD network.
No-Fault Automobile Insurance Law
The basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents.
Non-Network Hospital (also referred to as ‘Out-of-Network’ Hospital)
A Hospital (as defined in this Glossary) which does not participate in the NYULMC/HJD (“Top Tier “) network or
UnitedHealthcare’s General (“Middle Tier) network.
Non-Network Provider (also referred to as ‘Out-of-Network’ provider)
A provider which does not participate in the Top Tier network or the UnitedHealthcare General Network (Middle
Tier network).
Nurse-Midwife
A person who is licensed or certified to practice as a Nurse-Midwife and fulfills both of these requirements
A person licensed by a board of nursing as a registered nurse
A person who has completed a program approved by the state for the preparation of Nurse-Midwives.
Nurse Practitioner
A person who is licensed or certified to practice as a Nurse-Practitioner and fulfills both of these requirements:
A person licensed by a board of nursing as a registered nurse.
A person who has completed a program approved by the state for the preparation of Nurse-Practitioners
Other Services and Supplies
Services and supplies furnished to the individual and required for treatment, other than the professional services of
any Physician and any private duty or special nursing services (including intensive nursing care by whatever name
called ).
Physician
A legally qualified:
Doctor of Medicine (M.D.)
Doctor of Chiropody (D.P.M.; D.S.C.)
Doctor of Chiropractic (D.C.)
Doctor of Dental Surgery (D.D.S.)
Doctor of Medical Dentistry (D.M.D.)
Doctor of Osteopathy (D.O.)
Doctor of Podiatry (D.P.M.)
Plan
The Employee’s medical benefits described in this Summary Plan Description
Psychologist
A person who specializes in clinical psychology and fulfills one of these requirements:
A person licensed or certified as a Psychologist
A member of Fellow of the American Psychological Association, if there is no government licensure or certification required.
Reasonable Charge (also referred to as “Allowable Charges”)
As to charges for services rendered by or on behalf of an ‘In- Network’ Physician, an amount not to exceed the
amount determined by UnitedHealthcare in accordance with the applicable fee schedule.
As to charges rendered by or on behalf of an ‘Out-of-Network’ Physician, an amount not to exceed ‘110% of the
Medicare rate’ for a covered health service under the Plan.
Rehabilitation Facility
A facility accredited as a Rehabilitation Facility by the Commission on Accreditation of Rehabilitation Facilities.
Review or Review Process
A review and determination that the services and supplies are Covered Health Services.
Room and Board
Room, board, general duty nursing, intensive nursing care by whatever name called, and any other services regularly
furnished by the Hospital as a condition of occupancy of the class of accommodations occupied, but not including
professional services of Physicians nor special nursing services rendered outside of an intensive care unit by whatever
name called.
Sickness
The term “sickness” used in connection with newborn children will include congenital defects and birth abnormalities, including premature births.
Skilled Nursing Facility
If the facility is approved by Medicare as a Skilled Nursing Facility then it is covered by this Plan.
If not approved by Medicare, the facility may be covered if it meets the following tests:
It is operated under applicable licensing and other laws
It is under the supervision of a licensed Physician or registered graduate nurse (R..N.) who is devoting full
time to supervision.
It is regularly engaged in providing Room and Board and continuously provides 24-hour-a-day skilled nursing care of sick and injured persons at the patient’s expense during the convalescent stage of an injury or
Sickness.
It maintains a daily medical record of each patient who is under the care of a licensed Physician.
It is authorized to administer medication to patients on the order of a licensed Physician.
It is not, other than incidentally, a home for the aged, the blind or the deaf, a hotel a domiciliary care home,
a maternity home, or a home for alcoholics or drug addicts or the mentally ill.
A Skilled Nursing Facility which is part of a Hospital will be considered a Skilled Nursing Facility for the purposes
of this Plan.
Treatment Center
A facility which provides a program of effective Mental Disorder Treatment and meets all of the following requirements:
It is established and operated in accordance with any applicable state law.
It provides a program of treatment approved by a Physician and UnitedHealthcare
It has or maintains a written, specific and detailed regimen requiring full-time residence and full-time participation by the patient.
It provides at least the following basic services:
Room and Board (if this Plan provides inpatient benefits at a Treatment Center)
Evaluation and diagnosis
Counseling
Referral and orientation to specialized community resources
A Treatment Center which qualifies as a Hospital is covered as a Hospital and not as a Treatment Center.
Benefit Summary
NYU
Hospitals Center
1/1/2013
Basic Plan
PPO
PPO BASIC
BENEFIT
NYULMC & HJD
UNITEDHEALTHCARE
NETWORK
(Participating Providers)
GENERAL
UNITEDHEALTHCARE
NETWORK
OUT-OF-NETWORK
Copays are not applied to annual
deductible amounts
Mental Health/Substance Abuse Deductible $500 per person
FINANCIAL
Deductible
Employee
Employee + One
Employee + Two or more
None
None
None
$300
$600
$900
$1,200
$2,400
$3,600
Non-Notification Penalty
$400
$400
$400
Coinsurance
20%
20%
50%
$2,000 (Includes copays)
$4,000 (Includes copays)
$6,000 (Includes copays)
$3,500 (Includes deductible & copays)
$7,000 (Includes deductible & copays)
$10,500 (Includes deductible & copays)
$6,000 (excludes deductible & Hospital copay)
$12,000 (excludes deductible & Hospital copay)
$18,000 (excludes deductible & Hospital copay)
Unlimited
Unlimited
Unlimited
No Charge
No Charge
Subject to deductible & coinsurance
No Charge
Immunizations
No Charge
(Adult Immunizations limited to nontravel related)
No Charge
Subject to deductible & coinsurance
No Charge
Subject to deductible & coinsurance
$20 copay per visit
20%
$40 copay per visit
$150 copay per surgery, then subject
to deductible & coinsurance
Subject to deductible & coinsurance
Subject to deductible & coinsurance
Laboratory services
Radiology Services
No Charge
20%
No Charge
Subject to deductible & coinsurance
Subject to deductible & coinsurance
Subject to deductible & coinsurance
ALLERGY CARE
Initial visit and all subsequent
referral visits
Injection only, waive copay
$20 copay per visit
$40 copay per visit
Subject to deductible & coinsurance
HOSPITAL CARE
Physican and Surgeon’s services*
Semi-private room and Board*
Notification required
20%
20%
Subject to deductible & coinsurance
Subject to deductible & coinsurance
$500 copay per hospital admission,
copay per hospital admission not
applicable if readmitted to the same
hospital within 90 days of initial admission for same diagnosis
Subject to deductible & coinsurance
Subject to deductible & coinsurance
$1000 copay per hospital admission,
copay per hospital admission not applicable
if readmitted to the same hospital within 90
days of initial admission for same diagnosis
Inpatient drugs and medications
20%
Subject to deductible & coinsurance
Subject to deductible & coinsurance
No Charge
No Charge
No Charge
Out-of-Pocket Maximum
Employee
Employee + One
Employee + Two or more
Lifetime Maximum Benefit
(per member)
PREVENTIVE CARE
Physical examination
Routine pediatric care
OUTPATIENT CARE
Physician Office visits
Surgery
EMERGENCY CARE
(UnitedHealthcare must be contacted
within 48 hours if admitted)
Ambulance services when Medically
Necessary
At hospital emergency room
$50 copay, waived if admitted, $50 copay, waived if admitted: then
coinsurance would then apply $500 per hospital admission copay
applies, then deductible & coinsurance would apply
$50 copay, waived if admitted: then $500
per hospital admission copay applies, then
deductible & coinsurance would apply
PPO BASIC
BENEFIT
NYULMC & HJD
UNITEDHEALTHCARE
NETWORK
(Participating Providers)
GENERAL
UNITEDHEALTHCARE
NETWORK
OUT-OF-NETWORK
OUT OF AREA CARE
EMERGENCY
Emergency Room
$50 copay, waived if admitted, $50 copay, waived if admitted: then
coinsurance would then apply $500 per hospital admission copay
applies, then deductible & coinsurance would apply
$50 copay, waived if admitted: then $500
per hospital admission copay applies,
then deductible & coinsurance would
apply
Outpatient Care
N/A
Subject to deductible & coinsurance
Subject to deductible & coinsurance
Prenatal and post-natal care*
Hospital services for mother*
20%
20%
Subject to deductible & coinsurance
$500 copay per admission
see Hospital Care above
Subject to deductible & coinsurance
$1000 copay per hospital , then subject
to deductible & coinsurance
see Hospital Care above
Routine healthy newborn inpatient
nursery care
No Charge
No Charge
Subject to deductible & coinsurance
Inpatient
Notification is required for inpatient
care
20%
$500 copay per admission, then subject to deductible and coinsurance.
$300 does not apply
$500 annual per person deductible
(mental health/substance abuse and
standard plan deductible expenses cross
apply) & Coinsurance ($1,200 deductible
does not apply)
Outpatient care***
$20 copay per visit
$40 copay per visit
Same as inpatient above
Inpatient
Notification is required for inpatient
care
No Charge
No Charge
$500 annual per person deductible
(mental health/substance abuse and
standard plan deductible expenses cross
apply) & Coinsurance ($1,200 deductible
does not apply)
Outpatient***
No Charge
No Charge
Same as inpatient above
HOME HEALTH CARE
200 home care visits per calendar
year*
20%
Subject to deductible & coinsurance
Subject to deductible & coinsurance
N/A
Subject to deductible & coinsurance
Subject to deductible & coinsurance
$30 copay
Subject to deductible & coinsurance
20%
Subject to deductible & coinsurance
Subject to deductible & coinsurance
ONLY if an in-network provider is not
available, otherwise not covered
20%
Subject to deductible & coinsurance
Same as above
MATERNITY CARE
MENTAL HEALTH CARE
SUBSTANCE ABUSE
Notification required
SKILLED NURSING FACILITY
200 days per calendar year*
Notification required
CHIROPRACTIC CARE
$1,000 benefit maximum per calendar N/A
year
HOSPICE CARE
Inpatient Care*
Notification required
$210 day max per calendar year Outpatient Care*
Notification required
PPO BASIC
BENEFIT
NYULMC & HJD
UNITEDHEALTHCARE
NETWORK
(Participating Providers)
GENERAL
UNITEDHEALTHCARE
NETWORK
OUT-OF-NETWORK
$20 copay
$40 copay
Not covered
$20 copay per visit
$40 copay per visit
Subject to deductible & coinsurance
Subject to deductible & coinsurance
Subject to deductible & coinsurance
INFERTILITY TREATMENT
Assisted Reproductive Technology
(ART), Artificial Insemination, Invitro Fertilization,GIFT, ZIFT
$10,000 benefit maximum per lifetime
REHABILITATION THERAPY
90 outpatient visits per therapy per
calendar year.
Inpatient covered services are limited
to a combined total 200 days of con- 20%
finement in a Hospital, Skilled Nursing Facility and Rehabilitation Facility
each calendar year
OTHER ITEMS
Durable Medical Equipment and
Medical Supplies****
Notification required
20%; requires advance notification to UnitedHealthcare
and must be obtained from a
NYULMC Durable medical
equipment provider
Subject to deductible & coinsur- Subject to deductible & coinsurance
ance; requires advance notification
to UnitedHealthcare and must be
obtained from a UnitedHealthcare
Durable medical provider.
AUTISM SPECTRUM
DISORDER
$20 co-pay per visit then
100% of eligible expenses
$40 co-pay per visit then 100% of 50% of eligible expenses after satisfying
eligible expenses
$1,200 deductible.
Coverage provided for screening,
diagnosis and treatment of autism
spectrum disorder. Provides coverage
for applied behavior analysis provided
or supervised by a Board Certified
Behavior Analyst up to $45,000 a year
* These services require advance notification to UnitedHealthcare. You must call UnitedHealthcare at 866-936-6007 at least 14 days in advance of treatment
to medical management. For Emergency Admissions, you must call UnitedHealthcare at 866-936-6007 within 48 hours if admitted. Failure to notify
UnitedHealthcare in advance will result in a $400 penalty.
** Plan maximums will be applied separately to different types of therapy.
*** Members who choose to use an out-of-network/clinician will need to call United Behavioral Health (UBH) to receive an authorization. Please note that the
initial authorization allows for 10 visits only per out of network clinician. The member will need to provide UBH with the name and address of treating provider/clinician . UBH will send a letter and an Outpatient Treatment Report to the provider advising that 10 visits have been authorized along with instructions on how to obtain authorization for additional visits beyond the 10 that are initially allowed. The Outpatient Treatment report is a 16 question form for the
provider to complete and fax or mail back to UBH. This form will be reviewed by a clinical team with UBH to determine if additional visits beyond the initial
10 authorized should be allowed. Members who utilize in-network providers call UBH prior to treatment to secure an open certification which allolws them to
see any network provider for up to 12 months. During treatment, members will receive a wellness assessment to complete at certain treatment intervals,
which is designed to assess their functioning. In Network first 10 visits are approved no precert required. Then for additional visits follow Out-of-Network.
Members who utilize in-network providers call UBH prior to treatment, members will receive a wellness assessment to complete at certain treatment inter
vals, which is designed to assess their functioning.
**** These services require advance notification to UnitedHealthcare. You must call UnitedHealthcare at 866-936-6007 at least 14 days in advance of treat
ment to notify medical management. Hearing aids are limited to a maximum reimbursement of $350 per 24 month period.
Benefit Summary
NYU
Hospitals Center
1/1/2013
Plus Plan
PPO
PPO PLUS
BENEFIT
NYULMC & HJD
UNITEDHEALTHCARE
NETWORK
(Participating Providers)
GENERAL
UNITEDHEALTHCARE
NETWORK
OUT-OF-NETWORK
Copays are not applied to annual
deductible amounts
Mental Health/Substance Abuse Deductible $500 per person
FINANCIAL
Deductible
Employee
Employee + One
Employee + Two or more
None
None
None
$200
$400
$600
$1,200
$2,400
$3,600
Non-Notification Penalty
$400
$400
$400
Coinsurance
10%
10%
40%
$1,500 (Includes copays)
$3,000 (Includes copays)
$4,500 (Includes copays)
$2,500 (Includes deductible & copays)
$5,000 (Includes deductible & copays)
$7,500 (Includes deductible & copays)
$6,000 (excludes deductible & Hospital copay)
$12,000 (excludes deductible & Hospital copay)
$18,000 (excludes deductible & Hospital copay)
Unlimited
Unlimited
Unlimited
No Charge
No Charge
Subject to deductible & coinsurance
No Charge
Immunizations
No Charge
(Adult Immunizations limited to nontravel related)
No Charge
Subject to deductible & coinsurance
No Charge
Subject to deductible & coinsurance
$10 copay per visit
10%
$30 copay per visit
$150 copay per surgery, then subject
to deductible & coinsurance
Subject to deductible & coinsurance
Subject to deductible & coinsurance
Laboratory services
Radiology Services
No Charge
10%
No Charge
Subject to deductible & coinsurance
Subject to deductible & coinsurance
Subject to deductible & coinsurance
ALLERGY CARE
Initial visit and all subsequent
referral visits
Injection only, waive copay
$10 copay per visit
$30 copay per visit
Subject to deductible & coinsurance
HOSPITAL CARE
Physican and Surgeon’s services*
Semi-private room and Board*
Notification required
10%
10%
Subject to deductible & coinsurance
Subject to deductible & coinsurance
$300 copay per hospital admission,
copay per hospital admission not
applicable if readmitted to the same
hospital within 90 days of initial admission for same diagnosis
Subject to deductible & coinsurance
Subject to deductible & coinsurance
$600 copay per hospital admission,
copay per hospital admission not applicable
if readmitted to the same hospital within 90
days of initial admission for same diagnosis
Inpatient drugs and medications
10%
Subject to deductible & coinsurance
Subject to deductible & coinsurance
No Charge
No Charge
Out-of-Pocket Maximum
Employee
Employee + One
Employee + Two or more
Lifetime Maximum Benefit
(per member)
PREVENTIVE CARE
Physical examination
Routine pediatric care
OUTPATIENT CARE
Physician Office visits
Surgery
EMERGENCY CARE
(UnitedHealthcare must be contacted
within 48 hours if admitted)
Ambulance services when Medically
Necessary
At hospital emergency room
No Charge
$50 copay, waived if admitted: then
$50 copay, waived if admitted, $300 per hospital admission copay
coinsurance would then apply applies, then deductible & coinsurance would apply
$50 copay, waived if admitted: then $300
per hospital admission copay applies, then
deductible & coinsurance would apply
PPO PLUS
BENEFIT
NYULMC & HJD
UNITEDHEALTHCARE
NETWORK
(Participating Providers)
GENERAL
UNITEDHEALTHCARE
NETWORK
OUT-OF-NETWORK
OUT OF AREA CARE
EMERGENCY
Emergency Room
$50 copay, waived if admit- $50 copay, waived if admitted: then
ted, coinsurance would then $300 per hospital admission copay
applies, then deductible & coinsurapply
ance would apply
$50 copay, waived if admitted: then $300
per hospital admission copay applies,
then deductible & coinsurance would
apply
Outpatient Care
N/A
Subject to deductible & coinsurance Subject to deductible & coinsurance
Prenatal and post-natal care*
Hospital services for mother*
10%
10%
Subject to deductible & coinsurance Subject to deductible & coinsurance
$300 copay per admission
$600 copay per hospital , then subject to
see Hospital Care above
deductible & coinsurance
see Hospital Care above
Routine healthy newborn inpatient
nursery care
No Charge
No Charge
Subject to deductible & coinsurance
Inpatient
Notification is required for inpatient
care
10%
$300 copay per admission, then
subject to deductible & coinsurance
$500 annual per person deductible &
coinsurance for mental health related
charges ($1,200 deductible does not apply)
Outpatient care***
$10 copay per visit
$30 copay per visit
No Charge
No Charge
$500 annual per person deductible &
coinsurance for substance abuse charges
($1,200 deductible does not apply)
No Charge
No Charge
Same as inpatient above
MATERNITY CARE
MENTAL HEALTH CARE
Same as inpatient above
SUBSTANCE ABUSE
Inpatient
Notification is required for inpatient
care
Outpatient Care
HOME HEALTH CARE
200 home care visits per calendar year* 10%
Notification required
Subject to deductible & coinsurance Subject to deductible & coinsurance
SKILLED NURSING FACILITY
200 days per calendar year*
Notification required
N/A
Subject to deductible & coinsurance Subject to deductible & coinsurance
CHIROPRACTIC CARE
$1,000 benefit maximum per calendar
year
N/A
$30 copay
HOSPICE CARE
Inpatient Care*
Notification required
$210 day max per calendar year
10%
Subject to deductible & coinsurance Subject to deductible & coinsurance
ONLY if an in-network provider is not
available, otherwise not covered
10%
Subject to deductible & coinsurance Same as above
Outpatient Care*
Notification required
Subject to deductible & coinsurance
PPO PLUS
BENEFIT
NYULMC & HJD
UNITEDHEALTHCARE
NETWORK
(Participating Providers)
GENERAL
UNITEDHEALTHCARE
NETWORK
OUT-OF-NETWORK
$10 copay
$30 copay
Not covered
$10 copay per visit
$30 copay per visit
Subject to deductible & coinsurance
INFERTILITY TREATMENT
Assisted Reproductive Technology
(ART), Artificial Insemination, Invitro Fertilization,GIFT, ZIFT
$10,000 benefit maximum per lifetime
REHABILITATION THERAPY
90 outpatient visits per therapy per
calendar year.
Inpatient covered services are limited
to a combined total 200 days of con- 10%
finement in a Hospital, Skilled Nursing Facility and Rehabilitation Facility
each calendar year
OTHER ITEMS
Durable Medical Equipment and
Medical Supplies****
Subject to deductible & coinsurance Subject to deductible & coinsurance
Notification required
10%; requires advance notification to UnitedHealthcare and
must be obtained from a
NYULMC Durable medical
equipment provider
Subject to deductible & coinsur- Subject to deductible & coinsurance
ance; requires advance notification
to UnitedHealthcare and must be
obtained from a UnitedHealthcare
Durable medical provider
AUTISM SPECTRUM
DISORDER
$10 co-pay per visit then 100%
of eligible expenses
$30 co-pay per visit then 100% of 50% of eligible expenses after satisfying
eligible expenses
$1,200 deductible.
Coverage provided for screening,
diagnosis and treatment of autism
spectrum disorder. Provides coverage
for applied behavior analysis provided
or supervised by a Board Certified
Behavior Analyst up to $45,000 a year
* These services require advance notification to UnitedHealthcare. You must call UnitedHealthcare at 866-936-6007 at least 14 days in advance of treatment
to medical management. For Emergency Admissions, you must call UnitedHealthcare at 866-936-6007 within 48 hours if admitted. Failure to notify
UnitedHealthcare in advance will result in a $400 penalty.
** Plan maximums will be applied separately to different types of therapy.
*** Members who choose to use an out-of-network/clinician will need to call United Behavioral Health (UBH) to receive an authorization. Please note that the
initial authorization allows for 10 visits only per out of network clinician. The member will need to provide UBH with the name and address of treating provider/clinician . UBH will send a letter and an Outpatient Treatment Report to the provider advising that 10 visits have been authorized along with instruct
ions on how to obtain authorization for additional visits beyond the 10 that are initially allowed. The Outpatient Treatment report is a 16 question form for the
provider to complete and fax or mail back to UBH. This form will be reviewed by a clinical team with UBH to determine if additional visits beyond the initial
10 authorized should be allowed. Members who utilize in-network providers call UBH prior to treatment to secure an open certification which allows them to
see any network provider for up to 12 months. During treatment, members will receive a wellness assessment to complete at certain treatment intervals,
which is designed to assess their functioning. .
**** These services require advance notification to UnitedHealthcare. You must call UnitedHealthcare at 866-936-6007 at least 14 days in advance of treat
ment to notify medical management. Hearing aids are limited to a maximum reimbursement of $350 per 24 month period.
THE EXCLUSIVE PROVIDER ORGANIZATION (EPO) AND
HEALTH MAINTENANCE ORGANIZATION (HMO)
Main Features
The Oxford EPO and Empire HMO plans emphasize health promotion through preventive services. Both
types of plans offer medical care through a network of participating doctors, hospitals and other healthcare providers. They contract with health care professionals and facilities to provide specified health care services at a fixed
cost. Each plan establishes its own guidelines ranging from the specific health care services offered to procedures
when obtaining care through their provider network. Although benefits vary the EPO and HMO generally feature:
No deductible or claim forms
100% coverage for most services after a co-payment
100% coverage for hospitalization
No coverage for health care obtained outside the HMO, except in an emergency
How the EPO and HMO Provide Benefits
To receive benefits, you and your eligible dependents must use the providers in the EPO or HMO’s provider network (participating network physicians, hospitals and other health care suppliers must provide all of your care). In
general, most of the cost of covered services are covered under the EPO or HMO plan you select. You make a copayment when you visit a participating provider and because you don’t have to pay up front for care, you do not
have to file paper claims. Services rendered outside the provider network are not covered, except in an emergency.
In addition, emergency notification procedures must be followed to receive the full amount of benefits.
When you join Empire HMO, you are required to select a Primary Care Physician (PCP) from the Empire HMO
network to handle your routine medical needs. Your primary care physician will coordinate the care you receive
from any other providers such as referrals to specialists or a hospital stay. You may select a PCP for yourself and
your enrolled dependents or designate different PCPs for each enrolled dependent.
Primary Care Physicians (PCPs) in an HMO are commonly referred to as "gatekeepers" because they determine
whether you need to be referred to a specialist. This means you are not authorized to see a specialist unless your
PCP approves or requests the consultation with a specialist. Your PCP is responsible for:
Diagnosing medical conditions
Ordering laboratory tests and x-rays
Delivering routine care
Arranging for HMO network specialist care and/or hospitalization when necessary
The selection of a Primary care Physician is not required under the Oxford EPO plan
Tools For Finding Participating Providers Near You
For Oxford EPO network providers….
Visit www.oxfordhealth.com online or call (800) 760-4566
For EMPIRE HMO network providers….
Visit www.empireblue.com online or call (800) 662-5193
Mental Health & Substance Abuse Benefits Under the EPO and HMO Plans
Impact of The Mental Health Parity and Addiction Equity Act
The Mental Health Parity and Addiction Equity Act of 2008 was enacted to make mental and substance abuse coverage comparable to how medical and surgical benefits are administered under Medical Plans. Effective for calendar
year plans on Jan 1, 2010, the Act requires Employers to make necessary changes to become compliant with this
legislation. The law does not require plans to provide mental health and substance use disorder benefits if they do
not already do so. However, what the law requires is certain changes to plans that provide these benefits to make
changes to their cost structures and benefits provisions. Effective January 1, 2010, mental health and substance
abuse benefits under the HMO Plans and the EPO plan are subject to the same copays and provisions that apply to
medical and surgical benefits to ensure equity and consistency in the way these benefits are covered under each plan
(refer to the Benefits Summaries for the EPO and HMO plans in this booklet to see how the Mental Health Benefits
and Substance Abuse benefits are covered under each plan).
Autism Spectrum Disorder Coverage Under the EPO and HMO Plans
Effective 1/1/2013, coverage is provided for the screening, diagnosis, and treatment of autism spectrum disorder
including: behavior health treatment (such as behavioral analysis), psychiatric care, therapeutic care, including nonrestorative therapy provided by licensed or certified speech therapists, occupational therapists, social workers, or
physical therapists, any other medical care provided by a licensed health care provider and augmentative communication devices.
Coverage is provided for applied behavior analysis provided or supervised by a Board Certified Behavior
Analyst up to a maximum covered amount of $45,000 a year. There are no age caps for services related to a diagnosis of Autism Spectrum Disorder and coverage can be provided to a child or adult covered member. There are
also no limits on the number of service visits, however coverage will end when the plan has paid the maximum allowed for the benefit of $45,000.
Expanded Coverage for Women’s Preventive Health Services
The Patient Protection and Affordable Care Act (PPACA)
New guidelines under PPACA require health plans to cover an expanded list of women’s preventive health services
effective 1/1/2013 at 100% (i.e without charging co-payments, co-insurance amounts, or applying deductibles)- see
below. In compliance, the Oxford EPO and Empire HMO plan provide coverage for these services as well:
Expanded coverage for Women’s Preventive Health Services covered at 100% effective 1/1/2013 includes:
Well-woman visits
Gestational diabetes screening for pregnant women
Domestic and interpersonal violence screening and counseling
FDA-approved contraception methods, and contraceptive education and counseling
Breastfeeding support, supplies, and counseling
HPV DNA testing, for women 30 or older
For More Information on the EPO and HMO Plans…..
After you enroll for coverage under an EPO or HMO plan, the insurance carrier will send you a
‘Member Handbook for Covered Services’ for the plan you elected. The Member Handbook will contain specific
information regarding benefits and plan provisions under the plan you elected. The Member Handbook may also be
accompanied or include your ‘Certificate of Coverage’ for the plan you elected as well as any amendments and/or
riders. In addition, the Member Handbook of the plan you select will also outline an Appeal Process for benefit
claims that you may dispute. For your reference, we also have provided Benefit Summaries for the Oxford
EPO and Empire HMO plan on the following pages which outline covered services under each plan.
Your Summary of Benefits
HMO
NYU Hospitals Center #376159
BENEFIT
IN-NETWORK 1
Lifetime Maximum
Dependent Children (covered to the end of the month)
Unlimited
Dependents to Age 26
Covered Preventive Services 6
Member Pays In-Network
Covered Adult Preventive Care
$0
Annual Physical Exam
$0
Well-Child Care (to age 19; including covered immunizations)
$0
Preventive Well-Woman Care (no PCP referral required)
$0
Home/Office/Outpatient Care
Member Pays in-Network
Home/Office Visits (PCP or Specialist)
$15 copay
webVisit2
$5 copay per online consultation
Emergency Room/Facility (initial visit per occurrence)
$35 copay (waived if admitted within 24 hours)
Ambulatory/Outpatient Surgery 3
$0
Presurgery Testing
$0
Anesthesia
$0
Chemotherapy, Radiation Therapy
$0
Routine Maternity Care
$0
Laboratory Tests
$0
X-rays/MRI 3/ MRA3, CAT 3, PET3, Nuclear Cardiology 3
$0
Allergy Testing & Treatment
$15 copay (waived for treatment)
Chiropractic Care5
$15 copay
Home Healthcare (up to 200 visits per calendar year)
$0
Home Infusion Therapy
$0
Hospice Care (up to 210 days per lifetime)
$0
Physical Therapy 3
(up to 30 visits per calendar year combined in home, office
or outpatient facility)
$15 copay in home or office
Speech/Language3, Occupational3, Vision Therapies3
(up to 30 visits per calendar year combined in home, office
or outpatient facility)
$15 copay in home or office
Your Summary of Benefits
HMO
NYU Hospitals Center
BENEFIT
IN-NETWORK 1
Cardiac Rehabilitation
$0
Second Surgical Opinion
$0
Kidney Dialysis
$0
Inpatient Care 3
Inpatient Hospital
$0
(As many days as medically necessary; semi-private room and board)
Surgery, Surgical Assistant, Anesthesia
$0
Physical Therapy, Physical Medicine or Rehabilitation
(up to 30 inpatient days per calendar year)
$0
Skilled Nursing Facility (Up to 120 days per calendar year)
$0
Mental Health4
Outpatient Visits in Office
$15 copay
Outpatient Visits in Facility
$0
Inpatient Care
(As many days as medically necessary; semiprivate room and board)
$0
Alcohol/Substance Abuse 4
Outpatient Visits In Office
$15 copay
Outpatient Visits in Facility
$0
Inpatient Detoxification
(as many days as medically necessary; semiprivate room and board)
$0
Inpatient Rehabilitation (up to 30 days per calendar year)
$0
Other
Medical Supplies6
Durable Medical Equipment 3,6
Prosthetics & Orthotics 3
Ambulance (Air Ambulance)
$0
$0
$0
$0
(1) A network provider must deliver all care with a PCP referral (2) A webVisit enables you to receive a covered medical consultation for a nonurgent matter from a participating provider who has agreed to provide webVisits to Empire members online. Confirm your provider’s participation
by contacting your provider of his/her office staff. Visit our website or call for more details. (3) Empire’s network provider must precertify innetwork services or services may be denied; Empire’s network providers cannot bill members beyond in-network copayment (if applicable) for covered services. For ambulatory surgery , preapproval is required for proposed cosmetic/reconstructive procedures, outpatient transplants and opthalmological or eye-related procedures. (4) Our Behavioral Healthcare Management Program must preapprove all mental health and alcohol/substance
abuse services (5) Empire’s network provider must obtain authorization for clinical/medical necessity for in-network services, or services may be
denied; Empire network providers cannot bill members beyond the in-network copayment for covered services (6) The following benefits, if provided in-network for preventive care, are not subject to copayment; mammography screenings, cervical cancer screening, colorectal screenings, prostate cancer screenings, hypercholesterol screenings, diabetes screenings for pregnant women, bone density testing, annual physical examinations and
up to two annual obstetric and gynecological examinations. Certain preventive benefits are subject to age and/or frequency limits. Consult policy for
complete details.
OXFORD HEALTH INSURANCE , INC.
EPO PLAN
Freedom Network
SUMMARY OF COVERAGE
NYU Hospitals Center 1/1/2012
BENEFIT
IN-NETWORK
FINANCIAL
Deductible:
Maximum Out-of-Pocket:
(Including Deductible)
Single
Family
None
None
Coinsurance
None
Single
Family
Not applicable
Not applicable
Maximum Lifetime Benefit per Member
Financial Accumulation Period:
Unlimited
Not applicable
PREVENTIVE CARE
Adult Preventive
Infant and Pediatric Preventive Care
Preventive Dental for Children (through age 11)
No charge
No charge
No charge
OUTPATIENT CARE
Primary Care Physician Office Visits
Specialist Office Visits
Outpatient Facility Surgery**
Laboratory Services
MRIs, MRAs PET Scan, CT Scan, Ultrasound**
Radiology Services**
$15 copay per visit
$15 copay per visit
No charge
At participating laboratories only: No charge
No charge
No charge
HOSPITAL CARE
Physician’s and Surgeon’s Services **
Semi-Private Room and Board**
All Drugs and Medication
No Charge
No Charge
No Charge
EMERGENCY CARE
Ambulance Service When Medically Necessary
At Hospital Emergency Room
No Charge
$50 copay per visit
(if member is admitted to the hospital, notification is required)
Emergency Care in Urgi-Center
$15 copay per visit
MATERNITY CARE
Prenatal and Post-Natal Care**
Hospital Services For Mother and Child
$15 copay per initial visit only
No Charge
SKILLED NUSRING FACILITY
180 days per Calendar Year**
No Charge
OXFORD HEALTH INSURANCE , INC.
EPO PLAN
Freedom Network
SUMMARY OF COVERAGE
NYU Hospitals Center 1/1/2012
HOSPICE CARE (210 days per lifetime combined Inpatient, Outpatient and Home Hospice)
Inpatient Care**
Outpatient care**
Home Hospice**
No Charge
No Charge
$15 copay per visit
HOME HEALTH CARE
120 visits per Calendar Year**
Physician House Calls
$15 copay
$15 copay per visit
SUBSTANCE USE DISORDER SERVICES
Inpatient Rehabilitation**
Outpatient Rehabilitation**
Office Visits**
No charge
$15 copay per visit
$15 copay per visit
MENTAL HEALTH CARE
Inpatient Care**
Outpatient Care**
Office Visits**
No charge
$15 copay visit
$15 copay visit
ALLEGERY CARE
Testing and Treatment
$15 copay per visit
CHIROPRACTIC CARE
Chiropractic Care
$15 copay per visit
SHORT TERM REHABILITATION
60 Consecutive Inpatient Days per condition/Lifetime** No Charge
60 Outpatient Visits per Condition/Lifetime**
$15 copay per visit
Precertification after initial visit
DURABLE MEDICAL EQUIPMENT
Durable Medical Equipment **
Unlimited
No Charge when ordered by a participating physician
(Precert required for items over $500)
MEDICAL SUPPLIES
Medical Supplies When Medically Necessary
Unlimited
No Charge when ordered by a participating physician
EXERCISE FACILITY
Subscriber
Spouse
$200 reimbursement per 6 month period
$100 reimbursement per 6 month period
ELECTIVE TERMINATION OF PREGNANCY
$350 maximum for one procedure per Calendar Year
No Charge
HEARING AIDS
Coverage is limited to $5,000 per Calendar Year
No Charge when ordered by a participating physician
Limited to a single purchase (including repair/replacement) every 3 years
** These services require precertification through Oxford. You must call Oxford at 1-800-444-6222 at least 14 days in advance of treatment to
request precertification. Out-of-Network Urgent Care , when properly precertified may be paid at member’s copay.
*** Mental health and substance use disorder services can be precertified through Oxford’s Behavioral Health Department by calling 1-800-201-6991
HOSPITAL DISCOUNT FOR NYUHC EMPLOYEES
Inpatient Hospitalization Discount
Eligible NYUHC employees, and their spouses, domestic partners and eligible dependent children
are eligible for an ‘Inpatient Room & Board Discount’ when hospitalized at Tisch Hospital or
Rusk Institute of Rehabilitation Medicine (RIRM), provided that they are covered under one of the
medical plans offered by NYUHC (i.e the UHC PPO plans, the Oxford EPO or any of the HMO
medical plans).
The inpatient room and board discount is a 25% reduction in the cost of the difference between a private and
semi-private room at Tisch Hospital or Rusk Institute Rehabilitation Medicine (RIRM). The provider should be
informed that you are an eligible employee or dependent before the service is rendered.
When all insurance payments have been made, a 25% reduction of your bill for the covered services eligible for the
discount will occur before you receive your final “balance due” statement.
Note: Covered expenses for a private room are limited to the regular daily charge made by the hospital for
a semi-private room.
Hospital Courses Discount
Eligible NYUHC employees and their spouses, domestic partners and eligible dependent children who are covered
under one of the medical plans offered by NYUHC are also eligible for a 35% discount on certain courses sponsored by the Health Education Center.
THE PRESCRIPTION DRUG PLAN
Prescription Drug Plan Options
Employees eligible for benefits under the BeneFlex Program and certain eligible employees under the BasicCare Program, have two prescription drug benefit options to choose from– the Basic Rx Plan and the Enhanced Rx Plan (both are administered by CVS/Caremark).
When you enroll in one of our medical plans - PPO, EPO or HMO plan - you are automatically enrolled in the
‘CVS/Caremark Basic Rx Plan’ at no additional cost ( if you waive medical coverage, prescription coverage is not
available). Prescription plan coverage will be provided for the same dependents you elect to cover under your
medical plan. However, eligible employees who wish to incur lower out-of-pocket expenses when using their prescription drug benefit, also have the option to elect and purchase coverage under the ‘CVS/Caremark Enhanced
Rx Plan’.
It is important to note that the Basic and Enhanced Rx plans cover the same prescription drug medications
based on the same preferred drug list (see section below on ‘The Preferred Drug List’)- there is no difference
among the two plans with respect to the prescription medications covered. The only difference between the
two prescription drug plans, is that there is cost associated with electing coverage under the Enhanced Rx Plan to
account for the lower out-of-pocket expenses you incur when utilizing the Enhanced Rx option.
Shortly after your enrollment under the Basic Rx or Enhanced Rx plan, you will receive a “Welcome Booklet” from
CVS/Caremark containing: 2 ID cards, a sample mail order claim form, and a pull-out summary reference sheet of
the Rx plan you are enrolled under. The co-pay amounts for the Rx plan you select will be listed on the back of
your CVS/Caremark prescription drug cards. However, please note that the names of any covered dependents will
not be listed on your prescription dug cards. Benefits for any covered dependents are listed under your name and
ID number. You will need to present your CVS/Caremark I.D. card each time you purchase prescription drugs at a
network pharmacy.
The Preferred Drug List
Coverage for prescription drug medications is based on the ‘CVS/Caremark Preferred Drug List’ which is a list of
preferred prescription drug medications (approved by the Food and Drug Administration) that CVS/Caremark
elects to cover because of their quality and cost-effectiveness. The preferred drug list is reviewed and updated regularly by CVS/Caremark to ensure that it includes a wide range of effective generic and brand name prescription
drugs. The prescription drug plan is based on a “three-tier” structure which determines your share of the cost for
your prescription drug medication(s) according to whether the drug is considered by CVS/Caremark to be ‘Generic’,
‘Preferred ‘ or ‘Non-Preferred’ .
The prescription drug tiers are defined as follows:
Generic Drugs: These drugs are “chemical copies” of their brand name equivalents. Generic prescription
drugs are tested and certified by the Food and Drug Administration (FDA) to be as effective as their brandname counterparts and satisfy the same FDA standards. You incur the least out-of-pocket expense for these
drugs .
Preferred Drugs : A list of brand-name drugs that CVS/Caremark selected to be covered under the Basic and
Enhanced Rx plan options because of their cost-effectiveness. You will incur lower co-payments for these
drugs because CVS/Caremark has negotiated special discounted prices for these medications with drug company
You can obtain the latest CVS/Caremark Preferred list from the NYULMC Benefits Services Department ,
download a copy via the HR Portal at www.nyuonsitehealth.org, or through the CVS/Caremark website at
www.caremark.com.
Non-Preferred Drugs: Non-Preferred drugs are medications that are NOT part of CVS/Caremark Preferred
Drug list and are the most expensive type of medication under the plan. A Non-Preferred Drug (s) may be pre
scribed for you by your Physician if he/she decides this is the most beneficial medication for you.
Filling Your Prescription Drug Medications
Under the prescription drug plan , you can fill your prescriptions for either a 30-day supply (for medications needed
on a short-term basis) or for a 90-day supply of medications needed on a long-term basis for chronic conditions).
30-day Supply of Short-Term Medications
(at Participating Network Pharmacies)
If your physician writes a prescription for a short-term medication, it will be filled for a 30-day supply at any participating CVS/Caremark pharmacy. When you have a prescription filled at a retail network pharmacy, you can take
advantage of the network’s discounted rates and typically pay less than if you have a prescription filled at a nonnetwork pharmacy.
CVS/Caremark has one of the largest network of participating pharmacies including many of the major pharmacy
chains such as CVS, Duane Reade, Walgreens, as well as local neighborhood pharmacies. For a list of network pharmacies, visit CVS/Caremark’s Website at www.caremark.com or call 1-877-232-8122.
If for some reason you must use a pharmacy that is not in the CVS/Caremark network, you will need to submit a
claim along with your receipts for prescription drug purchases for reimbursement directly to CVS/Caremark .
90-day Supply of Long-Term Medications
(at CVS Pharmacies, the NYUHC Pharmacy or the CVS/Caremark Mail Service Pharmacy)
If you use ‘long-term medications’ for chronic conditions (such as those taken for the treatment of hypertension,
asthma , diabetes, thyroid diseases, etc..), you should consider having your Physician write a 90-day prescription for
your long-term medication(s) in order to enjoy cost savings. When you have a prescription filled for a 90-day supply under the plan, your cost is significantly less than you would pay if you were to have your medication re-filled on
a 30-day supply basis.
It is important to note that 90-day supply of long-term medications can only be filled in three ways under
the plan:
(1) at CVS/pharmacy stores,
(2) the NYUHC Pharmacy
(3) or through the CVS/Caremark Mail Service Pharmacy (see section on CVS/Caremark Mail Service Pharmacy for more details )
Important Notes on Filling 90-day Long-Term Medications
“New” prescriptions for long-term medications must be filled for a 30-day supply first, before it can be filled for a
90-day supply .
A prescription is considered to be a new prescription if either of the following is true :
(1)
(2)
(3)
(4)
If you are filling the medication for the first time;
If the medication changes; OR
If the dosage or dosage frequency changes (i.e from taking one pill 2x a week to taking one pill 4x per day)
If it has been more than 1 year that you have taken the same medication and dosage.
However, keep in mind that the above process does not apply to long-term prescription medications currently filled
for a 90-day supply or existing 30-day prescriptions that you wish to fill as a 90-day supply.
This means that your existing prescription medications can be filled for a 90-day supply without having to be filled
as a 30-day prescription first, provided your physician writes a new prescription order to authorize the prescription
to be filled for a 90-day supply.
CVS/Caremark Mail Service Pharmacy
The CVS/Caremark Mail Service Pharmacy is designed to provide members with convenience as well as cost savings. With the mail service pharmacy, your long-term medications can be delivered to your home which saves time
as well as trips to a CVS/pharmacy store or NYUHC Pharmacy to get a 90-day supply of your prescribed longterm medications.
Also, for added convenience, when you sign up for the Mail Service Pharmacy, you can :
order prescriptions and obtain health information online at www.caremark.com
Speak to a registered pharmacist 24 hours a day, seven days a week
contact a pharmacist with your questions online at www.caremark.com
To use this service, all you need to do is send your prescription slip(s), mail service order form, and respective
copayment. CVS/Caremark usually delivers the order within 10 days of receiving your completed mail-order form.
Mail Service Pharmacy order forms, and envelopes can be obtained through CVS/Caremark directly at 1-877– 2328122 or you can download the order forms via CVS/Caremark’s website at www.caremark.com.
Prescription Drug Costs
Although the CVS/Caremark Basic Rx and Enhanced Rx plans are both subject to same Preferred Drug List for
covered prescription drugs, your copayments for your prescription drug medications are based on:
The plan selected (Basic Rx plan vs. Enhanced Rx plan)
The category your prescription medication(s) fall under (generic, preferred or non-preferred)
How your prescription is being filled (30-day or 90-day supply)
The table below outlines the prescription drug copayment structure for both the Basic and Enhanced
Rx options based on where the prescriptions are being filled:
PRESCRIPTION DRUG COPAYMENT TIER STRUCTURE
How a Prescription is
Filled...
In-Network Pharmacy &
NYUHC Pharmacy
(30 day short-term supply )
BASIC Rx PLAN
CO-PAYMENT TIERS
• Generic drugs: $10
• Preferred drugs: $25
• Non-Preferred drugs: $50
• Generic drugs: $20
Mail Service Pharmacy,
CVS Pharmacy or NYUHC • Preferred drugs: $50
Pharmacy
(90 day supply for
long-term medications)
• Non-Preferred drugs: $85
ENHANCED Rx PLAN
CO-PAYMENT TIERS
• Generic drugs: $10
• Preferred drugs: $20
• Non-Preferred drugs: $45
• Generic drugs: $20
• Preferred drugs: $40
• Non-Preferred drugs: $75
Special Discount with CVS ExtraCare Health Card
Shortly after enrollment in the CVS/Caremark prescription drug plan, you also receive a CVS ExtraCare
Health Card (in addition to your CVS/Caremark Prescription Drug ID Cards that you need to present to participating pharmacies in order to fill your medications).
When you use the CVS/Caremark ExtraCare Health Card, you receive a 20% discount on CVS brand FSA eligible health items such as allergy medications, pain relievers, first aid items and more
Types of Prescription Drugs Covered Under the Plan
The following are covered under the Prescription Drug plan and are subject to change:
Drugs that require a prescription by law, including those special classes listed below
Insulin, Insulin pen, Insulin pre-filled syringes, Insulin needles and syringes
Diabetes tests strips and reagents, lancets
Oral contraceptives* and patch contraceptives
Pre-natal vitamins requiring a prescription
Inhaler medications (note: coverage is provided only for inhaler medications not inhaler devices and supplies)
Oral Fertility medications
Specialty injectable medications
Tretinoin agents through age 24
Compound medication of which at least one ingredient is a Prescription Legend Drug
Plan Limits on Lifestyle Prescription Drugs
Both the CVS/Caremark Basic and Enhanced Rx plans have limits for certain covered lifestyle drugs under the plan.
They include the following :
The lifetime benefit for covered prescription drugs related to ‘infertility treatment’ is a maximum of $1,800.
‘Erectile dysfunction’ medications are limited to a monthly supply of ten (10) pills.
‘Weight management‘ medications require prior approval before coverage is provided under the plans.
Prescription Drugs Not Covered Under the Plan
The following prescription drugs are not covered under the Prescription Drug Plan, even if prescribed by your doctor:
Over-the-counter drugs– medicines or drugs that can be obtained without a prescription; including vitamin
and minerals
Therapeutic devices, appliances and durable medical equipment excluding glucose monitors
Investigational/experimental drugs
Medications used to enhance athletic performance
Immunization agents, biological sera, allergy serum, including Flu- Mist
Medication, legend or not, and any charge associated with its administration that is to be consumed by or
administered to you or your dependents , in whole or in part, while in a doctor’s office, hospital, extended
care facility, nursing home or similar institution (please note: medications administered to you or your dependents
while in a doctor’s office, hospital, extended care facility, nursing home or similar institution could be covered under your medical
plan).
Prescriptions dispensed after one year from the original date of issue
Drugs used solely for cosmetic purposes
Drugs that are considered cosmetic agents
Contraceptive devices
Prescription drugs that are not medically necessary
Legend Homeopathic drugs
Items covered under any present or future local, state or federal programs, including Worker’s Compensation
Refilling of a prescription in excess of the number specified, any refill dispensed after one year from the
order of a physician or dentist, or a after all refills of the prescription medication have been utilized.
Drugs that are nor approved for the diagnosis for which they have been prescribed or whose intended use is
illegal, unethical, imprudent, abusive or otherwise improper
Drugs obtained by unauthorized, frauulent, abusive or improper use of the I.D. card
Nutritional supplements and drugs or solutions intended for intravenous use
Drugs purchased you by and/or your dependent after date of coverage termination under the Prescription
Drug Plan
Drugs that treat hair loss
Ostomy Supplies
Inhaler devices
Prescription drugs when there is an equivalent available without a prescription (e.g. hydrocortisone 1% cream,
ibuprofen 200mg)
Smoking cessation products
Coordination of Benefits
The Prescription Drug Plan does not include a coordination of benefits provision. This means that prescription
drug benefits paid from CVS/Caremark are not coordinated with those you may be entitled to receive under any
other plan(s).
Also, if you or a covered dependent are covered under the prescription drug program as well as Medicaid or other
similar state program for prescription drugs, in most instances this program is your primary drug coverage. You
should purchase your prescription drugs using your CVS/Caremark ID card and submit out-of-pocket copay expenses to the Medicaid or other similar state program.
Keep in mind because the prescription drug plan does not have a coordination of benefits provision, you cannot
submit claims to CVS/Caremark for reimbursement after any other payor has paid primary or has made the initial
payment for the covered drugs.
Filing a Claim
As mentioned in the beginning of this section, when you have your prescription medications filled at retail pharmacies, you simply present your I.D. card at the time of purchase along with the corresponding co-payment for your
medication(s)- there are no claim forms to complete.
However, should you use an out-of-network pharmacy, you will be required to pay the pharmacist the full amount
for the prescription and then submit a claim to CVS/Caremark for processing. After you claim is processed, you
will be reimbursed for the purchase of your prescription medications based on the plan’s allowable amount, less
your applicable co-payment(s). Note: As a result your reimbursement could be less than your total expenses incurred.
Claim forms for reimbursement of prescription drug expenses can be obtained through the NYULMC Benefit Services Department, contact CVS/Caremark at 1-877– 232-8122 or you can download the order forms via
CVS/Caremark’s website at www.caremark.com.
Affordable Care Act Summary: Interim Final Rules for Adverse Benefit Determinations
The Patient Protection and Affordable Care Act (the “ACA”) imposed new claims and appeals standards on
non-grandfathered group health plans and insurance issuers. Interim final regulations (IFR) were issued in July 2010.
Based on comments from industry parties, amendments to the IFR were issued in June 2011.
These amendments will affect the way in which CVS Caremark administers clients’ claims and appeals
procedures. Key changes were made in five treatment areas: code requirements, turnaround times, compliance with procedures, member communications, and scope of requirements for federal appeal review. All
five areas are addressed below.
Part 1: Diagnosis and Treatment Codes Not Required in Denial Notices
Summary of Amendment: The initial guidance required non-grandfathered plans to include the diagnosis and/or
treatment code and their associated meanings in all adverse benefit determination (denial) notices.
Under the amendments effective January 1, 2012, that requirement has been eliminated. Instead, denial notices must notify members that the information will be provided upon request. Additionally the amendments clarified that a member’s request for diagnosis and treatment codes is not, by itself, to be treated as an appeal.
CVS Caremark Response
• CVS Caremark does not routinely collect diagnosis and treatment codes when processing initial claims or appeals.
If such information is collected, however, it is stored within the prior authorization system.
• The prior authorization system has been recently updated to automatically populate any available diagnosis and
treatment codes into the notices. Therefore, CVS Caremark will continue to collect those codes where available, and
include that information in the denial notices by 1/1/2012.
The standard template denial notices will be modified by 1/1/2012 to inform members that diagnosis and treatment codes listed on the letter (if any) are the only ones available from CVS Caremark, and to direct members to
their health care providers for additional information.
Part 2: Turn Around Times for Urgent Care Claims Summary of Amendment:
The government has elected to reinstate the 72-hour time frame to review urgent claims.
• Prior to the enactment of the ACA and the issuance of the IFR, the ERISA claims and appeals regulations required
a plan or issuer to review and notify a member of an initial determination on an “urgent”1care claim not more than
72 hours after receipt of the claim.
• The IFR shortened that time for review so the member was notified with a decision not more than 24 hours after
receiving the claim.
• Many plans/insurers raised concerns, stating that the longer review timeframe was needed in certain circumstances
so the quality of the review wasn’t negatively impacted.
• After weighing the costs and benefits of requiring an absolute 24-hour time limit for reviewing urgent care claims,
the government elected to reinstate the 72-hour time frame to review urgent claims. Note: the initial decision on an
urgent care claim must be made as soon as possible, but no later than 72 hours.
1 An “urgent” care claim is defined by the ERISA claims and appeals regulations as a claim for medical care or treatment with respect to which use of the time frames used for making non-urgent care determinations could: (i) seriously jeopardize the member’s life or health, or the member’s ability to regain maximum function; or (ii) in the opinion of a physician with knowledge of the member’s medical condition, would subject the member to severe pain that
cannot be adequately managed without receiving the care or treatment being requested.
Important: When determining whether a claim constitutes an “urgent care” claim, plans and issuers must defer to
the judgment of the attending provider (generally, the member’s physician).
CVS Caremark Response
• CVS Caremark will continue to review and make initial benefit determinations with respect to members’ urgent
care claims as soon as possible.
• Members will be notified of CVS Caremark’s determination not more than 72 hours after receipt of the claim.
• If a claim is marked “urgent” by a member’s physician, CVS Caremark will process it as an urgent care claim.
In some cases, CVS Caremark may contact the physician to confirm that the claim meets the ERISA requirements for an urgent care claim, but will continue to process the claim as urgent while attempting to do so.
Part 3: Strict Compliance with Claims and Appeals Procedures
Summary of Amendment: Effective 1/1/12, a member won’t be immediately eligible to request an ACAmandated external review or to bring a court case when a minor or harmless error or omission is made in the processing of the member’s claim or appeal.
The IFR originally allowed a member to seek immediate review of an adverse benefit determination (by requesting
ACA-mandated external review or bringing a court case) if a plan or issuer failed to “strictly adhere” to all of the
requirements for processing claims and appeals. This provision applied even if a plan or issuer substantially complied
with those requirements.
In response to concerns from plan sponsors advocating use of a “substantial compliance” approach:
• The Amendments add exceptions to the strict compliance requirement for errors that are minor and meet certain
other conditions. Exceptions include errors that are:
• De minimis, which means that they involve a minor error in processing
• Non-prejudicial, which means that the determination of the member’s claim or appeal was not affected by the error
• Attributable to good cause or matters beyond the control of the plan or issuer
• In the context of an ongoing, good-faith exchange of information between the member and the plan or issuer
• Not reflective of a pattern or practice of non-compliance.
The plan or issuer’s policies and procedures must be in compliance with the regulations.
Part 4: Provision of Culturally and Linguistically Appropriate Notices
Summary of Amendment: Plans must offer adverse benefit (denial) notices in any non-English language that is
spoken by 10% or more of the persons residing in any particular county. Currently, only four languages meet this
requirement: Spanish, Chinese, Tagalog, and Navajo. In addition, even if a member requests that a notice be translated into a particular language, plans are no longer required to send all subsequent communications in that language.
• The ACA requires plans and issuers to provide denial notices in a “culturally and linguistically appropriate manner.” The IFR initially required plans and issuers to provide notices in a particular non-English language if the number of persons covered by a plan or policy who were literate only in that non-English language met certain applicable
thresholds. The thresholds were based on the size of the plan or policy and whether group or individual coverage
was involved.
Comments about the IFR raised concerns about both the difficulty and cost of complying with the IFR’s notice requirements. In consideration of that feedback, the Amendments:
o Establish a single threshold of 10% for determining whether denial notices must be provided in a non-English
language. Therefore, plans and issuers must offer notices in any non-English language that is spoken by 10% or
more of the persons residing in any particular county, based on data published by the U.S. Census Bureau.
The Agencies have provided a sample statement in each of these languages that can be used to notify members of
the availability of translated notices.
o The Amendments permit plans and issuers to provide more than one statement in any of the four languages that
might be required for a particular state or states, rather than attempting to track the languages spoken in any particular county within the state or states.
The government released a list of counties nationwide where a non-English language is spoken by 10% or more of
the population.
CVS Caremark Response
CVS Caremark is currently developing a library of denial reasons in the four non-English languages currently required by the Amendments (Spanish, Chinese, Tagalog, and Navajo). In addition, the standard denial templates will
include a statement in each of the four specified languages alerting members of their ability to request the notice in
those alternate languages. CVS Caremark is also in the process of selecting a telephone service provider with the
ability to provide additional information to members in any of the applicable non-English languages.
Part 5: Narrowing of Scope of Determinations Eligible for Federal External Review
Summary of Amendment: The government is temporarily narrowing the scope of adverse benefit determinations
eligible for Federal external review. Requests for Federal external review initiated after September 20, 2011 with respect to claims or appeals involving only contractual or legal interpretation, without any use of medical judgment,
will no longer be eligible for Federal external review.
• Under the ACA, plans and issuers must provide members with an independent external review of final internal
denials.
o Self-funded plans must generally comply with a Federal external review process.
o Insured plans must generally comply with a State external review process.
o The IFR originally provided that any denial (including a final internal denial) could be reviewed under the Federal
external review process, except when the denial was based on eligibility. In contrast, many State external review
processes limit the scope of claims eligible for review to those involving medical necessity or medical judgment.
In response to concerns about the ability of IROs to appropriately review non-clinical claims, the government has
decided to temporarily narrow the scope of denials eligible for Federal external review.
• Therefore, a request for Federal external review that is initiated on or after September 20, 2011 will only be eligible
for such review if it (i) involves medical judgment as determined by the external Independent Review Organization
(IRO), or (ii) a rescission of coverage. Claims that involve only contractual or legal interpretation issues, and which
don’t involve medical judgment, will no longer be eligible for external review.
Be mindful that this decision is temporary and it is expected that the narrowed scope of review may be lifted by
January 1, 2014. If that should happen, all types of denials – whether based on medical judgment or not – would
again be eligible for Federal external review.
CVS Caremark Response
Because the determination of whether an adverse benefit determination involves “medical judgment” must be made
by an IRO, CVS Caremark will continue to triage requests for external review through the IAROS program as it currently does. CVS Caremark is in the process of confirming that the IROs with which it contracts will be responsible
for notifying members as to whether their request is eligible for Federal external review under the narrower scope.
No changes will be made to the standard denial notices used in connection with CVS Caremark’s review of clinical
claims. Denial notices related to administrative claims will be reviewed prior to September 20, 2011, to determine
whether additional changes should be made to those notices to comply with the requirements. CVS Caremark is
working with contracted IROs to determine if any pricing changes are required for the IRO’s initial review to determine whether a request for external review involves medical judgment.
CONTINUATION OF HEALTH COVERAGE
DURING LEAVES OF ABSENCE
If you are away from work due to an approved leave of absence, NYUHC may continue your employment and health
coverage under the Plan during your leave. The availability and period of continuation is determined by NYUHC
and its policies based on the type of leave.
Coverage will end either on:
The last day of the month following the month in which the leave begins for those leaves which are not other
wise specified in this section.
The date NYUHC notifies the insurance carrier that your employment has terminated and coverage is to be
ended.
Continuation of Health Coverage During Disability
NYUHC will continue your employment and coverage under this Plan during a period in which you are away from
work due to disability. The maximum period of continuation is six (6) months in accordance with the policies of
NYUHC .
Continuation of Health Coverage During Family and Medical Leave (FMLA)
The Family and Medical Leave Act of 1993 (FMLA) requires Employers to provide up to a total of 12 weeks
of unpaid, job-protected leave during any 12- month period to eligible Employees based on eligibility criteria
relating to certain family and medical reasons.
During FMLA leave, the employer must maintain the employee’s health coverage under “any group health” plan on
the same terms as if the employee had continued to work. Upon return From FMLA leave, most employees must be
restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms. Use of
FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee’s leave.
Any provisions for continuation of coverage under the Plan are intended to comply with the law and any pertinent
regulations , and its interpretation is governed by them.
Eligibility Requirements for FMLA
In order for you to be eligible for FMLA leave, all of the following criteria must be met:
You must work for a covered Employer (i.e. NYUHC)
You must work at a location where at least 50 employees are employed by the Employer or which is w i t h i n
75 miles of worksites that in the aggregate have 50 or more employees of the Employer.
You must have worked for the Employer for at least 12 continuous months.
You must have worked at least 1,250 hours over the previous 12 months.
You are eligible for leave under the FMLA as long as you have not exhausted your 12-week maximum within
the prior 12 months if you were previously notified of a prior absence counting toward your FMLA maximum.
Reasons for Taking FMLA Leave
Employees may apply for FMLA leave for any of the following reasons:
For incapacity due to pregnancy, prenatal medical care or child birth.
To care for the employee’s child after birth, or placement for adoption or foster care and assisting the
child in adjustment after placement (must be taken within 12 months after the birth or placement).
Caring for a child, parent or spouse with a serious health condition
For a serious health condition that make the employee unable to perform the employee’s job
A qualifying exigency arising out of the fact that your child, parent or spouse is on active duty or call to
active duty status in support of a contingency operation as a member of the National Guard or
Reserves.
Caring for a covered service member with a serious injury or illness sustained during active duty and you
are the child, parent, spouse or next of kin of that service member
Note: If both parents are employees, the combined length of the leave may not exceed twelve (12)
weeks for purposes of caring for their newly arrived child or for the employee’s sick parent.
Intermittent Leaves
It is important to note that an employee who requires leave due to his/her own serious health condition or to care
for a child, parent or spouse may, if medically necessary, take on an intermittent or reduced work schedule basis.
Any hours of leave taken intermittently or on a reduced basis are deducted on an hour-by-hour basis from the
aggregate 12-week entitlement. If the intermittent or reduced leave schedule is forseeable, based on planned medical
treatment, the employer may require the employee to temporarity transfer to an alternative position which better
accomodates recurring periods of leave, provided that the alternative position has the same pay and benefits.
Military Caregiver Leave
Permits an eligible employee who is the spouse, child, parent or next of kin to take up to 26 workweeks of leave to
care for a member of the Armed Forces, including a member of the National Guard or Reserves, who is undergoing
medical treatment, recuperation or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness sustained during active duty. This leave is only available during a single 12-month period and can equate to a combined total of 26 workweeks of FMLA leave during the single 12month period.
Requesting FMLA Leave- Advance Notice and Medical Certification
You must provide advance notice and medical certification to NYUHC when requesting FMLA leave. Your request to take FMLA leave may be denied if these requirements are not met:
You must provide 30 days advance notice when the leave is “foreseeable”. If the need for the leave is
unforeseen, notice must be given as soon as practicable
NYUHC may require medical certification to support a request for leave because of a serious health condition, and may require a second or third opinion (at NYUHC’s expense), monthly updates of medical docu
mentation and a fitness for duty report to return to work.
**Note: Certification of such illness may be required from the patient’s health care provider . Medical
certification must be provided as soon as possible, but in any event no later than 15 calendar days from
the date it is requested. Recertification from the health care provider may be requested on a regular
basis, but not more than every 30 days (for continuing, open-ended conditions it may be requested every
six months).
Employees will be required to use any sick time, as applicable, during this leave and subsequently take
unpaid time. Employees will also be required to use any vacation time, as applicable, during this leave
(can request to have up to two weeks remaining in the vacation bank) and subsequently take unpaid
time. Therefore, this leave may be both a paid and/or unpaid leave.
Continuation of Health Coverage, Job Benefits and Protection Under FMLA
NYUHC is required to maintain your health coverage for the duration of your FMLA leave.
The use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the
start of an employee’s leave.
The Plan benefits for yourself and your dependents will continue on the same terms as if you continued
to work. Upon return from FMLA leave, you must be reinstated to the same or an equivalent job with
equivalent pay, benefits, and other employment terms.
If you do not return to work following FMLA leave for a reason other than: (1) the continuation, recurrence, or onset of a serious health condition which would entitle you to FMLA leave; or (2) other circumstances beyond your
control, you may be required to reimburse NYUHC for our share of health insurance premiums paid on
your behalf during your FMLA leave.
WHEN HEALTH COVERAGE ENDS
Termination of Coverage
Your coverage under the Plan ends on the earliest of the following :
The day this Plan is terminated.
The last day of the month in which your last day of work occurs or the first day of the month if your last
day of work is the first day of the month.
The last day of the month in which you are no longer eligible for benefits coverage due to a change in status
The last day of a period for which contributions for the cost of coverage have been made, if the contributions for the next period are not made when due.
When Health Coverage Ends For Dependents
Coverage for your covered dependent(s) ends on the earlier of the following:
The day the employee’s coverage ends
The last day of a period for which contributions for the cost of Dependent coverage have been made, if
the contributions for the next period are not made when due.
Coverage for an individual Dependent ends on the earlier of:
The day before the Dependent becomes covered as an Employee under this Plan.
The last day of the month in which the Dependent stops being an eligible Dependent .
Continuation of Coverage for Incapacitated Dependent Children
A mentally or physically incapacitated child’s coverage will not be terminated due to age. Coverage will continue for
as long as Dependents coverage under the Plan is continued and the child continues to meet the following conditions:
The child is incapacitated.
The child is not capable of self-support.
The child depends mainly on the Employee for support.
You may be required to provide proof to your insurance carrier that your dependent child meets these
conditions and coverage will be approved by the carrier.
New York State Young Adult Law—Impact on Coverage for Dependent Children
Signed into law by Governor Patterson on 7/29/2009 (with an effective date of January 1, 2010 for our plans), the Young
Adult legislation requires NY State health plan insurers to offer parents optional coverage for unmarried children up to
the age of 29; regardless of financial dependence. However, under NYS Young Adult Law, coverage cannot be
provided to the young adult’s children . This legislation applies ONLY to fully-insured medical plans( for example ,our
HMO medical plans) The legislation does not apply to self-funded/self-insured plans, due to federal preemption under
the Employee Retirement Income Security Act (ERISA); which applies to our PPO, Prescription, Dental, and Vision
plans. Because our medical plans allow for dependent children to be covered until the end of the month in which
the 26th birthday occurs, the NYS Young Adult Law will impact those dependent children who fall outside of
this category up to the age of 29 (for more details on providing dependent coverage the NYS Young Adult Law
refer to the ‘Enrolling Dependent’ section of this booklet).
CONTINUATION OF HEALTH COVERAGE UNDER COBRA
NYUHC is required to offer continuation of health coverage to employees and dependents who are covered under
the Plan, as a result of the federal law that provides for this extended coverage - the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA). This plan provision to offer continued coverage is intended to comply with
the law and any pertinent regulations and its interpretation is governed by them.
Under COBRA, you and your eligible dependents have the option to continue health coverage, if your coverage ends
due to a ‘qualifying event’. COBRA also applies if you lose coverage because of retirement. If you elect to continue
coverage under COBRA, you are only allowed to continue the coverage in force immediately before your COBRA
‘qualifying event’.
Eligibility for COBRA Coverage
Listed below are the types of qualifying events that would constitute eligibility for continued coverage under COBRA :
termination of your employment for any reason (except for gross misconduct)
reduction in scheduled work hours that ends your eligibility
divorce or legal separation from your spouse or termination of your domestic partner relationship
your dependent child no longer qualifies as an eligible dependent child under the Plan (for example, a child
reaches age 26)
you become enrolled in Medicare
your death
The type of coverage being offered for continuation under COBRA will be the same type of coverage offered to
active employees by NYUHC and if there are changes made to those coverages offered to active Employees, those
coverage changes will also apply to COBRA recipients. Additionally, under COBRA, you are entitled to the same
rights to change elections as an active Employee or Dependent during the Annual Open Enrollment period as designated by NYUHC .
Eligible Dependents Under COBRA
Any of the following individuals are eligible for continued coverage provided they were covered as dependents under
your medical/prescription drug plan the day before your COBRA qualifying event:
your legal spouse or domestic partner
your former spouse (or legally separated spouse)
your dependent child or the child of your covered domestic partner, including a child born to or adopted dur
ing a period of continued coverage under COBRA.
Please note that although a domestic partner or his/her children are not deemed to be qualified beneficiaries under
COBRA, NYUHC offers continuation of coverage for eligible registered domestic partners and their eligible dependent children that is similar to COBRA continuation coverage.
COBRA Notification and Election
NYUHC will contact you (or in the case of your death, your eligible dependents) about any rights to continued coverage under COBRA at your expense. In the case of a divorce, separation or loss of a child’s dependent status, you
must notify the NYULMC Benefits Services Department in writing within sixty (60) days of the event. Failure to
notify the NYULMC Benefit Services Department will result in the loss of the opportunity to be offered COBRA.
Detailed information including the COBRA rate that must be paid will be sent to you and your eligible dependents by
NYUHC. NYUHC will charge you the full premium for the cost of your coverage, plus an additional 2% for administration.
If you want continued coverage under COBRA for you and/or your eligible dependents, you will need to make your
election during the later of the time frames specified below :
Within 60 days from the date NYUHC notifies you or,
The date on which your active coverage terminates
An election for continued coverage by you or your spouse or registered domestic partner is assumed to apply to all
dependents who would be affected by the qualifying event unless NYUHC is notified otherwise. If you or your eligible dependents do not choose to continue to make the appropriate contributions for continued medical/prescription
drug coverage, your participation in the medical and prescription drug plan will terminate as of the date your last payment covered.
The table below illustrates how long coverage under COBRA can continue:
COBRA CONTINUATION PERIODS
If original coverage ends because:
Maximum continuation period is:
Your employment terminates (except due to gross misconduct but including layoff or approved leave of absence) or your work hours are reduced so that you no
longer qualify for medical coverage
18 months for you and your covered dependents
Your dependent child no longer qualifies
36 months for that covered child
You and your spouse are divorced or legally separated
or your domestic partner relationship terminates
36 months for your covered spouse/domestic partner
and dependent children
You retire and become entitled to Medicare
36 months for your covered spouse and dependent children
You pass away
36 months for your spouse or domestic partner and
covered dependent children
Required Payments After COBRA Election
You have 45 days from the date of your COBRA election to make the first required payment for COBRA coverage.
The first payment will include any payment required as of the date of COBRA eligibility, (which is not necessarily the
date of your actual COBRA election).
Notification Requirements
You are required to notify your Employer within 60 days of when the following qualifying events occur*:
Divorce from your legal spouse
Legal separation from your spouse or termination of your domestic partner relationship
A covered dependent child is no longer an eligible Dependent
Loss of spouse’s employment and eligibility for coverage
Death of a dependent
* Failure to notify the NYULMC Benefits Services Department within 60days of when the aforementioned
qualifying events occur will result in the loss of your right to elect COBRA.
Second Qualifying Event
If a second qualifying event takes place while continued coverage is already in effect, then coverage may be extended.
The same procedures for notification apply to the second event. For example, if you take 18 months of coverage because of termination and you become eligible for Medicare during this time , your dependents may continue their coverage for up to 36 months from the date of your termination. In no case will continued coverage last longer than 36
months.
Social Security Disability and COBRA
COBRA continuation coverage may be extended an additional 11 months (from 18 months to 29 months) for you
and your dependents eligible for COBRA continuation coverage if Social Security determines that you or a dependent
were disabled on the date regular coverage ended or at any time before or during the first 60 days of COBRA continuation coverage. If you are eligible for the additional 11 months of COBRA coverage and have nondisabled dependents who are eligible to continue coverage, those nondisabled dependents are also eligible for the additional 11
months of continuation coverage.
To be eligible for the COBRA coverage extension to 29 months , you or your dependent must:
receive a determination from the Social Security Administration that you or your dependent were
disabled on the date of your termination or reduction in hours or that you became disabled within 60 days of
this date.
Notify and provide NYUHC with the disability determination within 60 days of receipt of the disability deter
mination and before the initial 18-month COBRA period ends, and
Agree to pay any increase in the required payment necessary to continue your coverage for the additional 11
months.
Note on Extension of Continuation Coverage Period in New York State
On July 29, 2009, Governor David A. Paterson signed into law legislation that extends state continuation coverage to 36
months, regardless of the qualifying event. Before the new state law went into effect, the length of time that a person
could have state continuation coverage depended on why the person was losing coverage.
New York State law extends state continuation coverage for an additional 18 months when combined with
federal COBRA continuation coverage, for a total of 36 months. However, the NYS 18 month period applies
only to fully insured medical plans such as our Empire HMO plan. The NYS extension of continuation coverage does NOT include continuation coverage for prescription, dental, vision or self-insured plans such as our UnitedHealthcare PPO medical plans. As a result, continuation coverage under our self insured medical plans and prescription, dental, and vision plans will be limited to the applicable federal COBRA Period (generally 18 months).
When COBRA Coverage Ends
Continued coverage will stop earlier than the maximum continuation period you are eligible for if:
you or your eligible dependent become eligible for Medicare benefits (however, if you are eligible for Medi
care , your family members may retain continuation of coverage for 36 months from the date you first be
came eligible for Medicare)
you or your dependents do not make the required payments.
you or your dependents obtain coverage under another group health plan with no pre-existing condition limi
tation.
Coverage was extended to 29 months due to a Social Security disability determination and there is a final de
termination that the covered individual is no longer disabled, or
NYUHC terminates the Plan
The following section is a notice of your rights under COBRA. This COBRA Notice contains important
information about your right to COBRA continuation coverage, which is a temporary extension of coverage
under the Plan.
GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS
INTRODUCTION:
You are receiving this notice because you have recently become covered under the NYU Hospitals Center Employee Benefit Plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA
continuation coverage, when it may become available to you and/or your eligible dependent(s) who are enrolled for
coverage as and as what you need to do to protect the right to receive it.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to your eligible dependents that are covered
under the Plan when they would otherwise lose their group health coverage. For additional information about your
rights and obligations under the Plan and under federal law, you should review this Summary Plan Description for
the Plan or contact a representative from the NYULMC Benefits Services Department.
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a
life event known as a “qualifying event”. Specific qualifying events are listed later in this notice. After a qualifying
event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary”. You, your
spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because
of a qualifying event. Continuation coverage is the same coverage that the Plan gives to other participants or beneficiaries under the Plan who are not receiving continuation coverage. Each qualified beneficiary who elects continuation coverage will have the same rights under the Plan as the other participants or beneficiaries under the Plan, including open enrollment rights. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage
pay full cost plus a 2% administrative fee.
If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan if
either one of the following qualifying events happens:
Your hours of employment are reduced, or
Your employment ends for any reason other than for your gross misconduct
If you are the spouse (or registered domestic partner) of an employee, you will become a qualified beneficiary
if you lose your coverage under the Plan if any of the following qualifying events happen:
Your spouse or registered domestic partner dies;
Your spouse’s or registered domestic partner’s hours of employment are reduced;
Your spouse’s or registered domestic partner’s employment ends for any reason other than for his or her gross
misconduct;
Your spouse or registered domestic partner becomes entitled to Medicare benefits (under Part A, Part B, or
both); or
You become divorced or legally separated from your spouse (or no longer register a domestic partner)
Your dependent children and (those of your domestic partner) will become qualified beneficiaries if they lose
coverage under the Plan if any of the following qualifying events happens:
The parent-employee dies;
The parent-employee’s hours of employment are reduced
The parent-employee’s employment ends for any reason other than for his or her gross misconduct;
▪ The parent-employee becomes entitled to Medicare benefits (under Part A, Part B, or both); or
The parent becomes divorced or legally separated from their spouse (or no longer register domestic partner)
The child stops being eligible for coverage under the plan as a “dependent child”
Sometimes, filing a proceeding in bankruptcy under title 11 or the United States Code can be a qualifying event. If a
proceeding in bankruptcy is filed with respect to your Employer and that bankruptcy results in the loss of coverage of
any retired employee covered under the Plan, the retired employee will become a qualified beneficiary with respect to
the bankruptcy. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified
beneficiaries if bankruptcy results in the loss of their coverage under the Plan.
You Must Give Notice of Some Qualifying Events
For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing
eligibility for coverage as a dependent child), you must notify the NYULMC Benefits Services Department within 60
days after the qualifying event occurs. You must provide this notice to a representative of NYULMC Benefits Services Department in order for continuation benefits to be extended. If notice is provided after 60 days your right to
continuation coverage may be denied.
How long will continuation coverage last?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after a member of NYULMC Benefits Services Department has been notified that a qualifying event has occurred. Each qualified beneficiary will have
an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation
coverage on behalf of their spouses, and parents may elect COBRA continuation on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage and can be provided up to 36 months if
the following were to occur:
When the qualifying event is the death of the employee, the employee’s becoming entitled to Medicare
benefits (under Part A, Part B, or both), your divorce, legal separation, termination of registered
domestic partnership, or a dependent child’s losing eligibility as a dependent child.
When the qualifying event is the end of employment or change to an ineligible status or the employee becomes
entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for
qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For
example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the
date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus
8 months). Otherwise, when the qualifying event is the end of employment or change to an ineligible status,
COBRA continuation coverage generally lasts for only up to a total of 18 months.
New York State law extends state continuation coverage for an additional 18 months when combined
with federal COBRA continuation coverage, for a total of 36 months. However, the NYS 18 month pe
riod applies only to fully insured medical plans such as our Empire HMO plan. The NYS extension
of continuation coverage does NOT include continuation coverage for prescription, dental, vision or
self- insured plans such as our UnitedHealthcare PPO medical plans. As a result, continuation coverage
under our self-insured medical plans and prescription, dental, and vision plans will be limited to the applicable
federal COBRA Period (generally 18 months).
There are two ways in which an 18 month period of COBRA can be extended:
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be
disabled and you notify the NYULMC Benefits Services Department in a timely fashion, you and your entire family
may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of
29 months. The disability would have to have started at some time before the 60th day of COBRA continuation
coverage and must last at least until the end of the 18-motnh period of continuation coverage. Documentation supporting a qualified beneficiary’s disability status must be submitted to NYULMC Benefits Services Department within 60 days of receiving the letter of determination from Social Security Administration. If you or anyone
in your family is determined to no longer be disabled under SSA, you must notify the Plan of that fact within 30 days
after that determination.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage,
the spouse (or registered domestic partner) and dependent children (and those of your registered domestic partner)
can receive up to an additional 18 months of COBRA continuation coverage, for a maximum of 36 months, if
notice of the second qualifying event is properly given to a representative of NYULMC Benefits Services
Department. This extension may be available to a spouse (or registered domestic partner) or dependent child (and
those of the registered domestic partner) receiving continuation coverage if the employee or former employee dies,
becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated (or no
longer is registered as a domestic partner), or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse, registered domestic partner or dependent child to lose
coverage under the Plan had the first qualifying event had not occurred. You must notify the Plan within 60 days
after a second qualifying event occurs if you want to extend your continuation coverage.
Continuation coverage will be terminated in the following instances:
The expiration of your continuation coverage per the Coverage Termination date
For you, your spouse or dependent , when such person first becomes, after electing COBRA coverage,
covered under any other group health plan (as an employee or otherwise) that (i) does not contain any
pre-existing condition or limitation applicable to the individual , or (ii) contains a pre-existing condition
exclusion or limitation, but it does not apply to the individual because he or she has been credited with
prior creditable health coverage for the duration of the exclusion or limitation period.
For you, your spouse or dependent, when such person first becomes, after electing COBRA for coverage eligible
for Medicare benefits (under Part A, Part B, or both)
Failure to pay the required monthly premium for the elected coverage(s) on time (within the applicable grace
period); or
Your Employer no longer maintains any group health plan
Continuation coverage may also be terminated for any reason the Plan would terminate coverage of participant or
beneficiary not receiving continuation coverage (such as fraud). You do not have to prove insurability to be eligible
for continuation of coverage. However, continuation of coverage is provided subject to your eligibility for coverage
under the Plan. NYU Hospitals Center (and the insurers) reserves the right to terminate your continuation coverage
retroactively if it is determined that you are not eligible for coverage. Once your continuation coverage terminates for any reason, it cannot be reinstated.
Electing Continuation Coverage
Shortly after your COBRA qualifying event, the NYULMC Benefits Services Department will provide you with a
COBRA Election Form along with your COBRA notice that must be completed by you if you wish to continue
group health coverage for yourself and/or your eligible spouse (domestic partner) and/or your eligible dependent
children. In order for election to be timely and valid, your COBRA Election Form must be postmarked or received
by the NYULMC Benefits Services Department within 60 days of the date on your COBRA notice.
You may elect to continue coverage on behalf of your eligible spouse (domestic partner) and/or eligible dependent
children who were covered under the Plan on the day before your COBRA triggering event by completing the
appropriate information on the Election Form. However, you may not decline coverage on behalf of your spouse to
elect continuation coverage and must complete the enclosed Election Form and return it to the NYULMC Benefits
Services Department in the coverage manner and within the time period described above. You, your spouse or parents decline coverage, an eligible dependent child also has an independent right to elect coverage him/herself by
completing an Election Form and returning it to NYULMC Benefits Services Department in the manner and within
the time period described above [note: if your completed election form is not received by Benefits Services within
the time frame described above, you (and your family) will permanently lose the right to elect continuation coverage.
You will not receive any further notices concerning your right to choose continuation coverage.
You may not elect coverage at this time for family members who are not currently covered under the Plan. However, coverage for eligible dependents may be obtained during the Plan’s annual open enrollment period. Coverage
may be elected for new dependents (i.e newborn or adopted children, or new spouse/domestic partner) during the
period of the employee’s continuation of coverage, provided that such dependents are enrolled within 30 days of the
qualifying event (i.e., the actual date of the birth, adoption or marriage/partnership). Contact the NYULMC Benefits Services Department if this applies to you.
In considering whether to elect continuation coverage, you should take into account that a failure to continue your
group health coverage will affect your future rights under federal law. First, you can lose the right to avoid having
preexisting condition exclusions applied to you by other group health plans if you have a 63-day gap in health coverage, and election of continuation coverage may help prevent such a gap. Second, you will lose the guaranteed right
to purchase individual health coverage that does not impose a preexisting condition exclusion if you do not elect
continuation coverage for the maximum time available to you. Finally, you should take into account that you have
special enrollment rights under federal law. You have the right to request special enrollment in another group health
plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after
your group health coverage ends because of the qualifying event listed above. You will also have the same special
enrollment right at the end of continuation coverage if you get continuation coverage for the maximum time available to you.
How much does COBRA continuation coverage cost?
Generally, each qualified beneficiary may be required to pay the entire cost of the continuation coverage. The
amount a qualified beneficiary may be required to pay may not exceed 102 percent of the cost to the group health
plan (including both employer and employee contributions) for coverage of a similarly situated plan participant who
is not receiving continuation coverage. The required payment for each continuation coverage period for each option
is described in this notice.
.
Paying for Continuation Coverage
Your initial premium payment must be received by NYULMC Benefits Services Department within 45 days from
the date that you elected and signed your COBRA form for continuation of coverage (this is the date the COBRA
Election Notice is post-marked, if mailed). Your initial premium payment must cover the number of months between your COBRA Coverage Begin Date and the date your COBRA fom is signed and returned. For example, if
your group health coverage ended January 31st, your COBRA Coverage Begin date would be February 1st. If you
elect COBRA continuation coverage on April 15th, you first premium payment would be for three (3) months
(February, March, and April). If you do not make your first payment for continuation coverage in full no later than
45 days after the date of your election, you will lose all continuation coverage rights under the Plan.
After your initial payment, each subsequent monthly payment is due on or before the “premium due date” which is
the 15th day of each month for coverage effective the following month. For example, coverage for the month of
June si due on May 15th. As specified by law, you have a 30-day grace period from the “premium due date” in
which to make a timely payment. Your premium payment must be received by the NYULMC Benefits Service Department within 30 days of the “premium due date” (the 15th day of each month) in order to avoid cancellation of
coverage for the following month.
You will not receive monthly bills for continuation coverage in accordance with our policy. Therefore, you must
remember to pay the required monthly premium on time. All checks or money orders should be made payable to
NYU Hospitals Center and should be mailed to the following address that has been designated for COBRA payments for NYU Hospitals Center.
Lock Box#418689
NYU Hospitals Center-COBRA Contribution, P.O. Box 418689, Boston, MA 02241-8689
If premium payments are not made in a timely manner and within the time periods described above, you (and your
family) will permanently lose your option to continue coverage and your coverage will be terminated as of the end of
the month for which your payment reflects the last monthly premium paid. Partial payments will not be accepted.
In addition, if the initial premium payment is not made on time, you (and your family) will lose coverage as of the
coverage termination date. Claims incurred will not be paid unless and until you elect continuation of coverage and
pay premiums on time for the applicable period.
Note: You may be entitled to have the state pay the premiums for your COBRA coverage. For more information
contact your local Department of Human Services.
Participants in the Health Care Flexible Spending Account (FSA)
If you are participating in the Health Care FSA, you may be eligible to continue to fund your account for the year in
which your qualifying event occurred on a post-tax basis with a 2% administrative fee if, as of the date of the qualifying event, you expect to incur expenses during the remainder of the plan year in order to receive a reimbursement
benefit that does not exceed the maximum amount you elected for that plan year. If you choose not to continue to
fund your account, eligible expenses incurred subsequent to your last day of employment are NOT eligible for reimbursement. If you have not incurred claims for the full amount in your healthcare account, the balance will be forfeited. Please contact the NYULMC Benefits Services Department (212-404-3787) for assistance in determining
whether you are entitled to continue coverage under the Health Care Flexible Spending Account Plan pursuant to
this rule. This does not affect your eligibility to continue your group medical, prescription, dental and vision coverage pursuant to COBRA.
If You Have Any Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to a representative of NYULMC Benefits Services Department. For more information about your rights under ERISA, including
COBRA, the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health
plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security
Administration (EBSA) in your area or visit the EBSA website at www.dol.gov.ebsa.
Keep Your Plan Informed of Address Changes
In order to protect your family’s rights, you should keep your Human Resources Department informed of any
changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send
to the NYULMC Benefits Services Department.
Plan Contact Information
Information about the Plan and COBRA continuation coverage can be obtained by submitting a request to the attention of the Benefits Services Department: at the following address:
NYULMC Benefits Services Department
One Park Avenue, 16th Floor (between 32nd and 33rd Streets)
New York, NY 10016
General Office # 212-4040-3787
General Fax#: 212-404-3900
E-mail:[email protected]
PRIVACY PRACTICES REGARDING YOUR HEALTH INFORMATION
NYU HOSPITALS CENTER
HEALTH AND WELFARE PLANS
and
HEALTHCARE REIMBURSEMENT PLANS
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
NYU Hospitals Center ("NYUHC"), as an employer is committed to protecting the privacy of health information maintained by the health
plans that are sponsored by each institution. This Notice is provided to you as required by the Health Insurance Portability and Accountability Act and the HIPAA Privacy Regulations (collectively, "HIPAA"). It applies to employees and covered dependents enrolled in NYU
Hospitals Center Health and Welfare Plans and Healthcare Reimbursement Plans which includes the following:
•
the Preferred Provider Plan (PPO Basic and Plus), administered by UnitedHealthcare
•
the Medicare Eligible Retiree Health Plan, administered by UnitedHealthcare
•
the Prescription Drug benefits administered by CVS/Caremark.
•
the Employee Assistance Program (EAP), administered by Corporate Counseling Associates.
It also applies to employees enrolled in the Healthcare Reimbursement Account Plan, administered by Wageworks.
This Notice describes how the NYUHC Health and Welfare Plans and Healthcare Reimbursement Account Plans (hereinafter, “the
Plans”) may use health information about you and your covered dependents and when such information may be used and disclosed.
This Notice also describes how you may have access to this information.
WHAT HEALTH INFORMATION IS COLLECTED?
The Plans consider personal health information to be confidential. The Plans will protect the privacy of that information in accordance
with federal and state privacy laws, as well as the Plans’ privacy policies. “Health Information” is used to mean information that identifies
you and relates to your medical history, such as the health care you receive and or the amounts paid for that care.
Health information subject to the provisions explained in this Notice is information maintained by the Plans. The provisions do not extend
to similar information which may be on file with NYUHC as an Employer in its normal course of doing business. The type of health information typically received and maintained by the Plans which is subject to this Notice includes claims information, benefit determinations,
appeals information, eligibility, and case management information.
SUMMARY OF PERMISSIBLE USES AND DISCLOSURES AND YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION WHICH DO
NOT REQUIRE YOUR AUTHORIZATION
In order to provide and administer your benefits, the Plans may use and disclose your health information in various ways
without your express authorization. These include:
•
Payment. The Plans may use and disclose your health information for purposes of paying for your health care services or to
obtain premiums/contributions from you. The Plans may also use and disclose your health information to make determinations
about your eligibility for benefit plan coverage, for coordination of benefits with other benefit plans, to perform claims management and collection activities, to review the medical necessity or the appropriateness of the care you received, and to conduct
utilization reviews such as pre-authorizations, or reviews, of services.
•
Health Care Operations. The Plans may use and disclose your health information as necessary to operate and manage their
business operations. For example, NYUHC on behalf of the Plans, has contracts with outside firms called third party administrators (TPAs) to provide administrative services to the Plans, e.g. UnitedHealthcare. The Plans may use your health information to
evaluate the performance of the TPA in managing and providing you with health care benefits. The Plans might use and disclose your health information to contract for reinsurance or to investigate the validity of benefits claims. In addition, the Plans
may share your health information with another company that performs certain services, such as billing or compiling information
to help the Plans determine how the Plans are doing relative to other health plans. Whenever the Plans have such an arrangement, they will have a written confidentiality agreement to ensure that the company that performs these services will protect the
privacy of your health information, maintain its confidentiality and limit the uses or further disclosures to the purpose for which the
information was disclosed or as required by law.
•
Benefits and Services. As part of their health care operations, the Plans may use your health information to contact you regarding benefits or services that may be of interest to you, such as benefits that are included in the Plans, your medical treatment, case management and coordination of benefits, recommendations for alternative treatments, therapies, health care providers or settings of care.
•
Employer. The Plans (with the exception of the EAP) may disclose certain health information to NYUHC since it is the Employer
that provides the NYUHC Health and Welfare Plans and Healthcare Reimbursement Account Plans. Upon a request from the
Employer, the Plans may disclose health information about enrolled employees and their covered dependents to enable NYUHC
to obtain premium bids from other health plans, or to modify, amend, or terminate the Plans; however, the information the Plans
disclose in such situations will not include any information that identifies individuals other than your zip code. The Plans may
disclose to NYUHC information on whether you are participating in, enrolled in, or disenrolled from the Plans. The Plans also
may disclose health information about you, including information that identifies you, only if it is necessary for NYUHC to administer the Plans. For example, the Employer may need such information to process health benefits claims, to audit or monitor the
business operations of the Plans, or to ensure that the Plans are operating effectively and efficiently. The Plans may also disclose information to the Employer with respect to workers' compensation and the Family and Medical Leave Act. The Plans,
however, will restrict NYUHC’s, use of your information to purposes related only to Plan administration. The Plans prohibits the
Employer from using your information for uses unrelated to Plan administration. Under no circumstances will the Plans disclose
your health information to your Employer for the purpose of employment-related actions or decisions or for the purpose of administering any other plan that the Employer may offer. Your Employer will only disclose the health information it received from the
Plans to third parties, such as to consultants or advisors, if the Employer has first obtained a confidentiality agreement from the
person or organization which will receive your health information. Health information that is maintained by the EAP is not disclosed to NYUHC as Employer.
•
Disclosures to Friends and Family Involved in Your Care and Payment for Your Care. The Plans may share information
about your health benefits to a person involved in your care such as a family member unless you object. If you have provided a
friend or family member with copies of your claim and other relevant identifying information, the Plans will assume that you do
not object.
•
Emergencies or Public Need. The Plans may use or disclose your health information in an emergency or for important public
needs. For example, the Plans may share your information with public health officials authorized to investigate and control the
spread of diseases. The Plans may have information to prevent or lessen a serious and imminent threat to health or safety.
•
As Required By Law. The Plans may use or disclose your health information if the Plans are required by law to do so. The
Plans will notify you of these uses and disclosures if notice is required by law.
•
Business Associates: The Plans may share information with UnitedHealthcare, CVS/Caremark and Wageworks who provide
administrative services for the Plans.
•
Research. In most cases, your written authorization will be obtained before using your health information or sharing it with others
in order to conduct research. However, under some circumstances, your health information may be used or disclosed without
your written authorization if approval is obtained through a special process to ensure that research without your written authorization poses minimal risk to your privacy. Under no circumstances, however, will researchers be allowed to use your name or identity publicly. Your health information may also be released without your written authorization to people who are preparing a future
research project, so long as any information identifying you does not leave our facility. In the unfortunate event of your death,
your health information may be shared with people who are conducting research using the information of deceased persons, as
long as they agree not to remove from our facility any information that identifies you.
USES AND DISCLOSURES OF HEALTH INFORMATION WHICH REQUIRE YOUR WRITTEN AUTHORIZATION
Except as otherwise described in this Notice in the previous sections, the Plans, through their third party administrators, will generally
obtain your written authorization before using your health information or disclosing it outside the Plans. If you provide the Plans with
such a written authorization, you may revoke that authorization at any time, except to the extent that the Plans have already relied on
it. To revoke an authorization, write to the Plans in which you are enrolled. Please refer to the contact list at the end of this Notice.
Access and Control of Your Health Information.
The Plans must provide you certain rights with respect to access and control of your health information in your health claims file.
Because the Plans have provided your information to a third party administrator (UnitedHealthcare, CVS/Caremark and Wageworks),
you must request access directly from the administrator that administers the Plan in which you are enrolled. Please refer to the contact
list at the end of this Notice. You have the following rights to access and control your health information
•
You generally have the right to inspect and copy your health information.
•
You have the right to request that the Plans amend your protected health information if you believe it is inaccurate or incomplete. You must submit your request in writing to the third party administrator of the Plan in which you are enrolled.
•
You have the right to receive from the Plans an accounting of disclosures of protected health information. Your request must be
in writing to the third party administrator (UnitedHealthcare, CVS/Caremark and Wageworks). Many routine disclosures the Plans
make, including disclosures to the Employer for Plan administration, will not be included in the accounting; the accounting will
identify only non-routine disclosures.
•
You have the right to request, in writing, further restrictions on the way the Plans use your health information or share it with
others. The Plans are not required to agree to the restriction you request, but if the Plans do, the Plans will be bound by the
agreement.
•
You have the right to request, in writing, that the Plans contact you in a way that is more confidential for you, such as at work instead of at home, if disclosure of your health information could put you in danger and you clearly state that in your request. The
Plans will accommodate all reasonable requests.
To Have Someone Act on Your Behalf
You have the right to name a personal representative who may act on your behalf to control the privacy of your health information.
Special Protections for HIV, Substance Abuse, and Mental Health Information
Special privacy protections may apply to HIV-related information, substance abuse information, and mental health information. Some
parts of this Notice may not apply to these types of information.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Plans or with the Secretary of the Department of
Health and Human Services. To file a complaint with the Plans, please contact:
Privacy Officer
NYULMC Benefits Services Department
One Park Avenue, 16th Floor
New York, NY 10016
No one will retaliate or take action against you for filing a complaint.
Copies of the Notice
The Plans may change their privacy practices from time to time. If that happens, the Plans will revise this Notice so you will have an
accurate summary of the Plans’ practices. The revised Notice will apply to all of your health information. If you received this Notice
electronically, you have the right to obtain a paper copy of the Notice. To request a paper copy of this Notice or any revised Notice,
please call the Privacy Officer at 212-998-1270. If this Notice is substantially revised, a new Notice will be mailed to you within 60 days.
You may also obtain a copy of this Notice or any revised Notice on your Employer’s HR website at www.nyuonsitehealth.org. The effective date of the Notice will always be located in the top right corner of the first page. The Plans are required by law to abide by the terms
of the Notice currently in effect.
Contact Information
For further information, please contact the Plans' Privacy Officer at 212-404-3787.
THIRD PARTY ADMINISTRATORS
To access and control your information, please direct your request to the following Third Party Administrators of:
NYUHC Health and Welfare Plans
NYUHC Health Healthcare Reimbursement Account Plans
Preferred Provider Organization and Retiree Health Plans
NYUHC Employee Assistance Program
NYUHC Group # 298662
Administered by Corporate Counseling Associates (CCA)
UnitedHealthcare
1-800-833-8707 ~ 24 hours/day 7 days/week
475 Park Avenue South @ East 32nd Street
New York, New York 10016
Customer Service – Privacy Unit
P.O. Box 740815
Atlanta, GA 30374-0815
1-866-936-6007 (NYUHC PPO and Under 65 Retirees)
1-866-844-4863 (Over 65 Retiree Health Plan)
Prescription Drug Benefits (for actives and Retirees)
CVS/Caremark
Group# NYUHC
1-877– 232-8122
Healthcare Flexible Spending Account Plan
NYUHC Group # 4203
Wageworks Inc.
Attn: Customer Service: HIPAA Info. Request
Two Waters Park Drive #250
San Mateo, CA 94403
1-800-924-3967
THE WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998
Your Rights After a Mastectomy
The Women’s Health and Cancer Rights Act (WHCRA) was signed into law by the United States Congress on
October 21, 1998. The Women’s Health and Cancer Rights Act (WHCRA) amended the Employee Retirement
Income Security Act of 1974 (ERISA) and the Public Health Service Act (PHS Act) and is administered by the
Departments of Labor (DOL) and Health and Human Services (DHHS).
WHCRA affects both group and individual health plans that provide medical and surgical coverage for a mastectomy. This act requires these health plans to provide coverage for reconstructive surgery and related services that
may follow a mastectomy.
In compliance with WHCRA, the medical plans offered by NYUHC cover the following services:
All stages of reconstructive surgery of the breast on which a mastectomy has been performed.
Surgery and reconstruction of the other breast to produce a symmetrical appearance.
Prostheses
Treatment of physical complications through all stages of a mastectomy, including lymphedema.
Coverage will be provided in a manner that is determined in consultation with the attending physician and the
patient.
Coverage of breast reconstruction benefits will be subject to the annual deductibles, co-insurance and co-payments
and all other terms and conditions of our medical plans that are in effect at the time service is provided, consistent
with those established for other benefits under the Plan .
Resources
Further information regarding WHCRA is available by contacting:
The Employee Benefit Security Administration’s toll free publications hotline at 1-866-444-EBSA (3272)
The U.S Department of Labor at www.dol.gov or 1-866-4-USA-DOL
Centers for Medicaid and Medicare Services at www.cms.hhs.gov or 1-877-267-2323
F
YOUR RIGHTS UNDER USERRA
THE UNIFORMED SERVICES EMPLOYMENT
AND REEMPLOYMENT RIGHTS ACT
USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services.
REEMPLOYMENT RIGHTS
HEALTH INSURANCE PROTECTION
You have the right to be reemployed in your civilian job if you leave
that job to perform in the uniformed service and:
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 for up to 24 months in the military.
you ensure that your employer receives advance written or verbal
notice of your service;
you have five years or less of cumulative service in the uniformed
services while with that particular employer;
you return to work or apply for reemployment in a timely manner
after conclusion of service; and
you have not been separated from service with a disqualifying discharge or under other than honorable conditions.
If you are eligible to be reemployed, you must be restored to the job
and benefits you would have attained if you had not been absent due
to military service or, in some cases, a comparable job.
RIGHT TO BE FREE FROM DISCRIMINATION AND
RETALIATION
If you
are a past or present member of the uniformed service;
have applied for membership in the uniformed service; or
are obligated to serve in the uniformed service;
then an employer may not deny you:
initial employment;
reemployment
retention in employment
promotion; or
any benefit of employment
Even if you don’t elect to continue coverage during your military service,
you have the right to be reinstated in your employer’s health plan when
you are reemployed, generally without any waiting periods or exclusions (i.e
pre-existing condition exclu sions) except for service connected illnesses or
injuries.
ENFORCEMENT
The U.S. Department of Labor, Veterans Employment and Training Service
(VETS) is authorized to investigate and resolve complaints of USERRA
violations.
For assistance in filing a complaint, or for any other information on
USERRA,contact VETS at 1-866-4-USA-DOL or visit its website at
http://www.dol.gov/vets. An interactive online USERRA Advisor can be
viewed at http//www.dol.gov/elaws/userra.htm.
If you file a complaint with VETS and VETS is unable to resolve it, you may
request that your case be referred to the Department of Justice for representation.
You may also bypass the VETS process and bring a civil action against an
employer for violations of USERRA.
because of this status
In additon, an employer may not retaliate against anyone in the
enforcement of USERRA rights, including testifying or making a
statement in connection with a proceeding under USERRA, even if
that person has no service connection.
The rights listed here may vary depending on the circumstances. This notice was prepared by VETS, and may be viewed on the internet at this address:
http://www.dol.gov/vets/programs/userra/poster.htm. Federal law requires employers to notify employees of their rights under USERRA, and employers may meet
this requirement by displaying this notice where they customarily place notice for employees.
IMPORTANT LEGAL INFORMATION
NYU Hospitals Center (NYUHC) provides you with this Summary Plan Description (SPD) outlining the provisions of medical and prescription drug benefits of the NYU Hospitals Center Health & Welfare (“the Plan”) .
This Summary Plan Description booklet describes the Employer-sponsored medical and prescription drug benefits
under the Plan. The medical and prescription drug benefits are “self-insured”. This means that all benefits under
the Plan are funded by NYU Hospitals Center (NYUHC).
The benefits described in this Summary Plan Description are sponsored by NYU Hospitals Center and NYU
Hospitals Center has entered into an arrangement with United Healthcare Service LLC and CVS/Caremark to
administer the processing of benefit claims and other services for the medical and prescription drug plans respectively.
Plan provisions are stated in the “Plan Document”, the legal document governing your benefits and rights under the
Plan. NYUHC has discretionary authority to interpret and administer the plan and to make factual determinations.
If there is a conflict between statements in this Summary Plan Description and the Plan Document, the Plan
Document will govern the administration of the Plan.
NYUHC reserves the right to amend or terminate the Plan at any time.
The Plan Document is available for inspection at the Benefit Services Department. Any questions about the Plan
should also be addressed to the Benefit Services Department.
This Summary Plan Description contains legally required information about the NYU Hospitals Center Health
& Welfare Plan (or “the Plan”), including some very important details of your rights under the law if a claim for
benefits is denied.
Summary of Benefits and Coverage, or SBC
The Patient Protection and Affordable Care Act (PPACA) requires that you are provided with an easy-to-understand summary
about your health plan’s benefits and coverage. The new regulation is designed to help you better understand and evaluate your health
insurance choices. The new regulation requires that you receive:
•
A short, plain language Summary of Benefits and Coverage, or SBC
•
A uniform glossary of terms commonly used in health insurance coverage, such as "deductible" and "copayment"
All insurance companies and group health plans must use the same standard SBC form to help you compare health plans. The SBC
form also includes details, called “coverage examples,” which are comparison tools that allow you to see what the plan would generally
cover in two common medical situations. You have the right to receive the SBC when shopping for or enrolling in coverage or if you request a copy from your issuer or group health plan. You may also request a copy of the glossary of terms from your health insurance
company or group health plan. You can access a copy of the SBC for the NYU Langone Medical Center health plans on the HR
benefits portal at www.nyuonsitehealth.org.
GOVERNING PLAN DOCUMENTS
This booklet is your Summary Plan Description for purposes of the Employee Retirement Income Security Act of
1974 (ERISA). The purpose of the Summary Plan Description is to highlight essential plan provisions as well as your
rights and obligations under the NYUHC Health & Welfare Plan, provided that you are an eligible participant of the
Plan.
Please be advised that all the details of the Medical Plan may not be contained in this Summary Plan Description. The
NYUHC Health & Welfare Plan is governed by a more explicit legal document. This means that should any question
ever arise about the nature and extent of your benefits, the formal language of the legal Plan Document (and not the
informal wording of the plan provisions as contained in this Summary Plan Description) will govern.
For more information about the Plan Document and your rights under the law, refer to the section titled “A
Covered Person’s Rights Under ERISA”.
NYUHC reserves the right to change or discontinue this Plan at any time, for any reason. This Summary
Plan Description does not create a contract of employment.
Name of Plan
NYU Hospitals Center Health & Welfare Plan
Name & Address of Employer who is the Plan Sponsor
NYU Hospitals Center
One Park Avenue, 16th Floor, Benefits Services
New York, NY 10016
Employer Identification Number of Plan Sponsor (EIN) :
13-3971298
Agent for Legal Process
Office of Legal Counsel
550 First Avenue, Room MSB-153
New York, NY 10016
Plan Number (PN): 507
Plan Type
The Plan described in this Summary Plan Description is a “Welfare Benefit Plan” for purposes of ERISA
Plan Years
The financial records of this Plan are kept on a Plan Year basis. The Plan Year begins each January 1 and ends each
December 31.
Plan Administrator
NYU Hospitals Center
One Park Avenue, 16th Floor New York, NY 10016 , Benefits Services
Telephone Number of Plan Administrator
212-404-3714
Type of Administration:
The Plan is administered on behalf of the Plan Administrator by United Healthcare Service LLC. The benefits are
paid from funds provided by the Employer on behalf of the Plan in accordance with a contract with United Healthcare Service LLC, Islandia, New York.
Source of Contributions and Funding:
This Plan is funded by direct benefit payments from the general assets of the Employer. The employee’s contribution toward the cost of this Plan is at a rate determined by the Employer.
Plan Details
The provisions of this medical plan relating to eligibility to participate and termination of eligibility as well as a description of the benefits provided by this Plan are described in detail in this Summary Plan Description which precedes this ERISA information.
Plan Amendment and Termination
The Plan Sponsor reserves the right to modify, suspend, or terminate this Plan at any time. The Employer does not
promise the continuation of any benefits nor does it promise any specific level of benefits at or during retirement.
Any benefits, rights or obligations of participants and beneficiaries under this Plan following termination are described in detail in this Summary Plan Description which precedes this ERISA information.
A COVERED PERSON’S RIGHTS UNDER ERISA
As a participant in the Health and Welfare Plan, you are entitled to certain rights and protections under the
Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be
entitled to:
Receive Information About Your Plan and Benefits
Examine, without change, at the plan administrator’s office and at other specified locations, such as work
sites and union halls, all documents governing the plan, including insurance contracts and collective bar gain
ing agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S.
Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefits
Ad ministration.
Obtain, upon written request, to the plan administrator, copies of documents governing the operation
of the plan, including insurance contracts and collective bargaining agreements and copies of the latest
annual report (Form 5500 Series) and updated Summary Plan Description. The administrator may make
a reasonable charge for the copies.
Receive a summary of the plan’s annual financial report. The plan administrator is required by law to
furnish each participant with a copy of this Summary Annual Report.
Continue Group Health Plan Coverage
Continue health care coverage for yourself, spouse or dependent if there is a loss of coverage under the plan
as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this
Summary Plan Description and the documents governing the plan on the rules governing your COBRA
continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group
health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA
continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after
you lose coverage. If you would like to request a copy of your HIPAA Certificate, please contact the NYULMC
Benefits Services Department.
PRUDENT ACTIONS BY PLAN FIDUCIARIES
In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for
the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of the plan,
have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may terminate your employment, or otherwise discriminate
against you in any way to prevent you from obtaining a (pension, welfare) benefit or exercising your rights under
ERISA.
ENFORCE YOUR RIGHTS
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was
done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan
documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a
Federal court. In such case, the court may require the Plan administrator to provide the materials and pay you up to
$110 per day until you receive the materials (unless the materials were not sent because of reasons beyond the control of the administrator). If you have a claim for the benefits which is denied or ignored, in whole or in part, you
may file suit in a state or Federal court. In addition, if you disagree with a relations order or a medical child support
order, you may file suit in Federal court.
If it should happen that plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting
your rights, you may seek assistance from the U.S. Department of Labor, or may file suit in a federal court.
The court will decide who should pay court costs and legal fees. If you are successful, the court may order the
person who was sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees,
for example, if it finds your claim is frivolous.
ASSISTANCE WITH YOUR QUESTIONS
If you have any questions about the NYUHC Health & Welfare Plan , you should contact the Plan Administrator.
If you have questions about this statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the plan administrator, you should contact the nearest office of the Pension and Welfare Benefits
Administration, U.S. Department of Labor, listed in your telephone directory, or the Division of Technical Assistance and the Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue
N.W., Washington, D.C. 20210.
You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.
One Park Avenue (between 32nd & 33rd Sts)
16th Floor
New York, NY 10016
Phone: 212-404-3787
Fax: 212-404-3900
Email: [email protected]
October 2012