UC Health and UC Physicians Partnership Effective January 1, 2012

Applicable to all employees covered under a UC medical plan

UC Health and University of Cincinnati Physicians (UCP) are pleased to announce a partnership with the University of Cincinnati (UC) and its employees. Beginning on January 1, 2012, UC employees and their dependents enrolled in a Humana medical plan will receive 50 percent office visit co-pay reduction when seeing UCP physicians.

UCP is the Cincinnati area’s largest group of board-certified physicians with over 700 physicians practicing in every medical and surgical specialty.

A listing of UCP physicians eligible for the co-pay reduction is available on www.UCPhysicians.com.

• Go to www.UCPhysicians.com
• Click on the  Faculty/Staff heading in the upper right of the home page
• Click on University of Cincinnati listing

Federal Legislation Affecting Medical Plan

Health Care Reform - Adult Children

Both the federal goverment (through the Affordable Care Act) and the Ohio state government have passed legislation allowing older age children ("adult children") to remain covered under their parents' health insurance coverage. 

• Health Care Reform Information

Children's Health Insurance Program (CHIP)

If you are eligible for health coverage from your employer, but are unable to afford the premiums, some states have premium assistance programs that can help pay for coverage.

• Children's Health Insurance Program Information

Women's Health and Cancer Rights Act 

This act requires the medical plan to provide mastectomy benefits to cover the following procedures:

• reconstruction of the breast on which the mastectomy was performed,
• reconstructive surgery of the other breast to present a symmetrical appearance, and
• prosthesis and coverage for physical complications at all stages of the mastectomy procedure, including swelling associated with the removal of lymph nodes.

This change only affects the procedures in connection with mastectomy procedures.  It does not extend treatment for surgeries which are deemed to be cosmetic in nature, such as breast augmentation.

Newborns' and Mothers' Health Protection Act

This act requires the medical plan to provide hospital stays in connection with childbirth of no less than 48 hours for vaginal deliveries and no less than 96 hours for deliveries by Caesarean section.  Any exceptions to these minimum stay requirements must be made by the attending physician in consultation with the mother (or the newborn's authorized representative).

All copayments, deductibles, co-insurance, and precertification requirements are still applicable according to the medical plan's guidelines.

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First 1000 Plan

This plan is not available to all employee groups.  Check the Medical Coverage Comparison Chart.

The First 1000 Plan is a Point of Service (POS) plan which uses the Humana network of health care providers.  A provider directory may be accessed by logging on to the Humana website (Humana.com).

First 1000 is a consumer-driven medical plan for those employees who generally experience few medical expenses and are willing to pay out-of-pocket for medical expenses within the plan limits in return for no premium. 

The plan provides:

• coverage for catastrophic medical expenses,
• $500 annual benefit allowance per person to cover physician, hospital and laboratory services, xrays, preventative and wellness care.

Additional details can be found in the Summary Plan Description document:

• 2012 - All Represented Employees
• 2012 - Unrepresented Employees

The insured is responsible for:

• copays which are not covered by the benefit allowance,
• eligible expenses until the deductible and out-of-pocket limits are met.

The First 1000 option should be chosen only after careful consideration.  Please refer to the Medical Coverage Comparison Chart.

To receive the highest level of benefits under this plan, the insured must use the provider network; however he/she does not need to choose a primary care physician.

An insured may use providers outside the POS network; however, he/she will pay a greater share of eligible medical expenses.  In a true emergency, care by an out-of-network provider for a life-threatening illness or accidental injury will be covered at network benefit levels, provided the plan is notified within 24-48 hours.

No matter which health care provider the insured uses, he/she must follow specific plan guidelines.

HMO Plan

The Humana Premier HMO also uses the Humana network of health care providers and covers a wide range of services.  A provider directory may be accessed by logging on to the network provider (Humana.com). 

HMO Guidelines:

• The insured does not need to choose a primary care physician.
• The insured may use HMO specialists without a referral.
• If the insured uses a physician or facility that is not a participating provider in the Humana HMO network, benefits will not be paid.
• In the event of a true emergency, care for a life-threatening illness or accidental injury out of the service is covered, provided the plan is notified within 48 hours.
• Check with the physician(s) to ensure the drugs prescribed are listed on the formulary. All prescriptions must be written by a participating physician.
• For additional details refer to the Summary Plan Description document:
  
  • 2012 - AAUP Represented Faculty
  • 2012 - Represented - Excluding AAUP
  • 2012 - Unrepresented
    

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Point of Service Plan (POS)

The Humana National Point of Service (POS) plan uses the Humana network of health care providers. A provider directory may be accessed by logging on to the network provider (Humana.com).  To receive the highest level of benefits under the POS Plan, an insured must use the provider network; however, he/she does not need to choose a primary care physician.

The insured may use providers outside the POS network; however, he/she will pay a greater share of eligible medical expenses.  In a true emergency, care by an out-of-network provider for a life-threatening illness or accidental injury will be covered at network benefit levels, provided the plan is notified within 48 hours. 

For additional details, refer to the Summary Plan Description documents:

• 2012 - POS Unrepresented Employees
• 2012 - POS Represented Employees

No matter which health care provider the insured uses, he/she must follow specific guidelines for elective hospitalization and surgery.

Limitations

All of the medical plans have certain limits and exclusions that apply to the services they cover.  Limitations that the plans have in common include:

• A medically appropriate length of stay will be authorized whenever the insured member is admitted to the hospital.
• During each hospital stay, the plan will periodically review the need for continued inpatient care to avoid unnecessary hospitalization.
• Special rules apply if the insured is hospitalized when new coverage begins.  Contact the Human Resources department for more information.
• Some prescriptions drugs may require pre-authorization.
• Limits that are unique to a plan are summarized on the Medical Coverage Comparison Chart.  If an insured needs emergency care outside the area serviced by POS, HMO, or First 1000, keep in mind that benefits for this care may be limited.

Waiving Medical Coverage

An employee can waive medical coverage.  The employee does not have to certify that he/she has other medical coverage in order to choose the waiver of medical insurance; however, the Medical Waiver option should be chosen only after careful consideration.  Even though the employee may choose to waive coverage, if he/she is not covered by another medical plan he/she runs the risk of potentially catastrophic medical expenses in the event of serious illness or injury.  If the employee chooses to waive coverage, he/she may not enroll in medical coverage during the calendar year unless he/she has a qualified status change (QSC) and the change of coverage is consistent with the QSC.  If the employee chooses to waive medical coverage and he/she is eligible for the Medical Plan Credit, it will appear as a taxable addition to the employee's paycheck.

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Cost

The per month Employee Cost (your cost), Employer Cost, and Plan Cost can be found under Rates on the Benefits website.  If an employee elects to waive his/her coverage, he/she may be eligible to receive a dental plan credit. 

If an employee declines dental coverage when first eligible or during an annual enrollment period and wants to enroll the next year or has a qualified status change, the employee may select only the Basic Dental Plan.  (After enrolling in the Basic Dental Plan, the employee will be able to choose a different dental plan, if other plans are available.)

How it Works

The university's dental plans are administered by Humana and are known as 'passive' PPO dental plans.  This means that the employee can use any dentist he/she chooses.

All non-network dental benefits are based on the Usual, Customary, and Reasonable (UCR) charges for these services.  UCR limits are determined by Humana and are subject to change.  Acceptance of UCR limits is at the discretion of the non-network provider.  If the non-network provider does not accept the UCR limit, the employee is responsible for any amount not covered by UCR in addition to the deductible and coinsurance.

It is recommended the employee's dental provider submit a predetermination if the cost of his/her dental services will be $200 or more.  Humana will provide an estimate of the coverage amount based on the information submitted.

For most covered services, the employee pays a deductible before the plan pays benefits. After paying the deductible, the employee and the plan share the cost of most eligible expenses.  The amount the employee pays is based on whether or not the employee uses a dentist who is part of the plan's network.  If the employee uses a network dentist, the employee's share of the cost is based on the dentist's discounted fees, so the employee's costs are lower.  In addition, there is no balance billing when the employee uses a network dentist.  If the employee uses a non-network dentist, his/her share of the cost is based on the dentist's full fee.

No matter what dentist an employee uses, the amount of his/her deductible, coinsurance levels, and plan maximum stays the same (for example, the employee pays 20% of the cost for restorative services).  Each plan limits the amount of benefits each covered person can receive during the plan year.  An identification card will be issued to employees and should be presented to his/her provider for all dental services.

Keep in mind - If the employee elects the Health Care Flexible Spending Account (FSA), he/she can use it to reimburse deductibles, coinsurance, and other eligible expenses not covered by his/her dental plan.

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Limitations

Certain limits and exclusions apply to all of the plans.  These limitations include:

• A new dental plan will not cover certain ongoing treatment.  The definition of ongoing treatment differs by service.  Contact Humana for information about ongoing treatment.
• Orthodontia benefits are payable only for dependent children under age 19.  For new employees, the plans with orthodontia will cover the remaining treatment under the plan provisions if the appliance was installed prior to the employee's date of hire.
• Under the ortho plans, 25% of the total charge is payable when the appliance is installed.  Then, the balance of the total charge is paid in monthly or quarterly installments over the maximum number of months of expected treatment, up to the maximum lifetime benefit allowed in the plan selected.

Summary Plan Description

• AAUP Dental Plan 
• Basic Dental Plan
• Ortho Dental Plan
• High Dental Plan
• High Ortho Dental Plan

Waiving Dental Coverage

An employee can waive dental coverage. The employee does not have to certify that he/she has other dental coverage in order to choose the waiver of coverage.  If the employee chooses to waive dental coverage, he/she may not enroll in coverage during the calendar year unless he/she has a qualified status change (QSC) and the change of coverage is consistent with the QSC.  If the employee chooses to waive dental coverage and he/she may be eligible for the Dental Plan Credit, it will appear as a taxable addition to the employee's paycheck.

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