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Health Insurance Information

2011-12 USAGE GUIDE:  UICHOICE AND CHIP II

 

Using UIChoice

The UIChoice plan is a comprehensive health care program that covers hospital, medical, surgical, outpatient, and other health care services such as physical therapy.  Coverage is also provided for routine physicals, newborn care (including inoculations, scheduled visits, etc.), well-child checkups, treatment of mental health conditions, treatment of chemical dependency, and prescription drugs.

How an Individual Uses UIChoice

Health care under the UIChoice plan may be obtained from any provider you wish.  This plan includes three benefit levels.  The provider you choose automatically determines the plan benefit level within UIChoice.

YOU DO NOT HAVE TO PICK A PLAN LEVEL – THE PROVIDER YOU CHOOSE AUTOMATICALLY DETERMINES AT WHICH LEVEL THAT PARTICULAR CLAIM IS PROCESSED.

You can use any provider.  Plan Levels 1 and 2 will result in lower out-of-pocket costs for you.  While you can use any provider you want, there are advantages to using providers who have contracts with Blue Cross and Blue Shield.

In Iowa, participating providers will accept payment arrangements and file claims for you with Blue Cross and Blue Shield.  Payment is made directly to these providers.

Non-participating providers do not have contracts with Blue Cross and Blue Shield.  They do not agree to accept payment arrangements and are not responsible for filing claims for you.  Non-participating providers may charge more for health care than participating providers.  Payment is made to you and you are responsible for paying the provider.
Non-participating providers can bill you for the difference between what Blue Cross and Blue Shield will pay for a service and what they charge (balance billing).

When you are out-of-state, participating Blue Cross and Blue Shield providers will result in lower out-of-pocket costs for you.  If it is a state that allows balance billing, using a participating Blue Cross and Blue Shield provider should result in a lower balance bill.

In an emergency, if you cannot reasonably reach a participating provider, care received in an emergency room during the course of the emergency will be reimbursed as though the service was received from a participating provider.

Who Can Be Covered

Coverage is provided through Wellmark Blue Cross and Blue Shield of Iowa. There are four main contract options available:  employee only, employee and spouse, employee and children, and employee and family.

Children may be covered until the age of 26 without tax implications. Coverage for children who are full-time students or disabled can continue as long as they continue in that status.

The Internal Revenue Service (IRS) has determined that if an employer allows employees to insure dependent children past the age of 26 who do not qualify as the employee’s tax dependents, there is a value that must be added to the employee’s taxable salary when reporting income earned on the annual W-2.  The information can be viewed at: http://www.uiowa.edu/hr/benefits/health/fpsmse/taxable_ins_hd_fpsmse.html.

Domestic partners may also be covered on this policy. See the Domestic Partner Information on the University Benefits Office website for more information.

Dual University of Iowa employed spouses/partners and any children may not double insure each other or dependents under the plans where the University contributes towards the cost of the plans.  This includes the health, dental, and AD&D insurance policies - an individual may only be included once under these policies.

How Much an Individual Pays for Health Care Services

Health care under the UIChoice plan may be obtained from any provider you wish.  The provider you choose determines the plan benefit level and how much you pay.

Office visits with Level 1 providers have a $5.00 co-payment.  Level 2 providers have a $20.00 co-payment.  Level 3 providers have 40% co-insurance.

There is no physician charge or co-payment for a routine annual physical examination from a level 1 or 2 provider, and 40% coinsurance applies for a Level 3 provider.  There is a charge for Labs, tests, and imaging on all levels.

Preventive care services are not subject to co-insurance.

There is no co-payment or co-insurance for well-child care (children up to seven years of age) and/or immunizations on any of the levels.

Insureds will pay 20% for durable medical equipment.

When care is necessitated by an emergency, the individual's share of the emergency room costs will include a $50 co-payment and 10% of the charges with Level 1 and 20% of the charges with Level 2 providers.  Level 3 providers will be the same unless the visit is not coded as an emergency, then there will be a $50 co-payment and 40% co-insurance.  The $50 co-payment is waived regardless of the provider level if you are admitted to the hospital.

When an individual is admitted to a hospital, the individual will pay a $400 deductible for level 1 providers, $600 deductible for level 2 providers, and an $800 deductible for level 3 providers.  After the deductible is paid, the individual will pay 10% of the charges for Level 1 providers, 20% of the charges for Level 2 providers, and 40% of the charges for Level 3 providers, subject to the out-of-pocket maximum limits.

The coinsurance for outpatient hospital services including outpatient surgery, physician care, supplies, labs & imaging is 10% for level 1 providers, 20% for level 2 providers, and 40% for Level 3 providers - again, subject to the out-of-pocket maximum limits. 

Out-of-Pocket Maximum (OPM) Expenses for Individuals and Families

The UIChoice Plan provides an annual maximum limit for the out-of-pocket expenses for both individuals and families.  When the amount paid in co-insurance and deductibles equals the applicable OPM, the plan pays 100% of the covered charges for most additional medically-necessary expenses incurred during the remainder of the calendar year.

The OPM for the individual's expenses for Levels 1 and 2 combined is $1,700.  The OPM for all other contracts (family, employee and children, employee and spouse, etc.) is $3,400 for Levels 1 and 2 combined.

The OPM for Level 3 services is separate from the Level 1 and 2 OPM.  The OPM for Level 3 services is $2,000 for individuals and $4,000 for all other contracts.

The OPM for prescription drugs is $1,100 for individuals and $2,200 for all other contracts.

The amount paid by an individual for co-payments, for the treatment or care of infertility, or due to contract limitations are not included in computing the annual out-of-pocket amount.

If a plan member in any contract other than an individual contract (family, employee and children, employee and spouse, etc.) meets the individual OPM, the additional plan member/s continue to pay co-insurance and deductibles until the larger OPM for their contract is met.

The OPM can also be met when no individual plan member meets their individual OPM, but the combination of the out-of-pocket expenses for all the plan members meets the appropriate contract OPM.

Coverage for Prescription Drugs

This plan has a tiered prescription benefit.  This means for each prescription you will pay co-insurance, which will vary depending on the tier (or category) of the drug.

The co-insurance amounts are:

You can search the Wellmark drug list at http://www.wellmark.com/ to determine which tier specific medications are in.  The prescription plan is BlueRX Complete.

Participating pharmacies are responsible for submitting your prescription claims electronically.

The OPM expense provision for prescription drugs is separate from the medical OPM.  The insured is responsible for paying co-insurance on prescriptions (as described above) up to $1,100 for individuals or $2,200 for family in prescription drug cost.  Once the OPM has been met, the plan pays 100% of covered expenses incurred during the rest of the calendar year for drugs.

If you purchase a brand name drug when an FDA-approved “A”-rated generic equivalent is available, you are responsible for your co-insurance, plus any difference between the billed charge for the brand name drug and the billed charge for the generic.  This can result in you paying substantially higher costs than if you had chosen the generic drug.

If your physician feels it is important for you to have the brand name drug, they can write the prescription for the brand name drug with the direction “Dispense as written” on the prescription. In this situation, you will not be responsible for the difference between the billed charge for the brand name drug and the billed charge for the generic drug.

Certain drugs are limited per month, benefit period, or lifetime by drug-specific quantity limitations, or by step therapy requirements or prior authorization.  The limitations are determined by Wellmark based on medical necessity.  For a list of drugs subject to limitations, visit www.wellmark.com or check with your pharmacist or physician.

Care Providers

Provider Category

Level 1 Providers

Level 2 Providers

Level 3 Providers (PARTICIPATING Blue Cross/Blue Shield)

Level 3 Providers (NON-PARTICIPATING Blue Cross/Blue Shield)

Description

Providers from The University of Iowa Hospitals and Clinics, the Carver College of Medicine (CCOM), and UI Community Medical Services Clinics (CMSC).

Blue Choice network providers

These providers participate with a Blue Cross and Blue Shield Plan.

These providers do not participate with a Blue Cross and Blue Shield Plan.

Provider

Blue Cross and Blue Shield has contracts with these providers and they agree to accept payment arrangements.

Blue Cross and Blue Shield has contracts with these providers and they agree to accept payment arrangements.

Blue Cross and Blue Shield has contracts with these providers and they agree to accept payment arrangements.

Blue Cross and Blue Shield does not have contracts with these providers and they do not agree to accept payment arrangements.

Claim Settlement

These providers file claims for you.

Claims are settled directly with these providers.

These providers file claims for you.

Claims are settled directly with these providers.

These providers file claims for you.

Claims are settled directly with these providers.

These providers are not responsible for filing claims for you.  You may have to file your own claims.

Claims are settled with you, not these providers.

Participating Providers.  These providers accept Blue Cross and Blue Shield payment arrangements.  All hospitals in Iowa are participating providers and over 4,000 physicians in Iowa are also participating providers.

When you are out-of-state, participating Blue Cross and Blue Shield providers will result in lower out-of-pocket costs for you.  If it is a state that allows balance billing, using a participating Blue Cross and Blue Shield provider should result in a lower balance bill.  Balance billing is the practice of billing a patient for the fee amount remaining after the insurer payment and patient co-payment have been made.

Emergency Services.  If you receive emergency care for covered services and cannot reasonably reach a participating provider, emergency room care received during the course of the emergency will be reimbursed as though the services were received from a participating provider.  You will have a $50 co-payment which will be waived if you are admitted.

An emergency can be considered to be a medical condition that a prudent layperson (with an average knowledge of health and medicine) could reasonably expect to result in serious jeopardy to a person’s health in the absence of immediate medical attention.  The emergency services must be provided in an emergency room setting (not an urgent care center or physician’s office).

Providers at The University of Iowa Hospitals and Clinics

When care is provided at The University of Iowa Hospitals and Clinics, the individual and the provider will agree on the role residents will play in the individual's care.  An individual may choose to have all primary health care provided by faculty members.  When an individual is hospitalized, residents and medical students are an integral part of the staff which provides support for treatment by the faculty.

Health Care for Individuals Who Are Away from Iowa

Out-of State.  If you are in a state other than Iowa and require medical care, you may call Wellmark Blue Cross and Blue Shield of Iowa at (800) 810-BLUE (2583) for assistance in locating the closest participating provider in that state.  You can also find providers in other states through the Wellmark website:  www.bcbs.com/healthtravel/finder.html.  For covered services received in a state other than Iowa there are advantages to using providers who participate with the Blue Cross and Blue Shield Plan in that state.

Out-of-Country.  If it is necessary to receive covered services in a country other than the United States, it is advisable to contact Blue Cross and Blue Shield for assistance in locating the closest participating provider in that country.

Coordination with Medicare

Payment for care received under any of the retiree health plans by retirees 65 and older assumes that Medicare is your primary health insurance and the University policy is secondary.  The few exceptions to this are described in the Insurance Certificate.

All claims except prescription drug claims should be submitted first to Medicare.  Medicare will determine whether or not this is a covered benefit under their program and will pay based upon that decision.  Any amount not covered by Medicare will then be considered under your University retiree health plan.  Prescriptions can be filed directly with Wellmark.

If you do not have Medicare coverage, the retiree plans will follow the same coordination procedure as stated in the UIChoice Retiree Insurance Certificate, but you will be responsible to pay the amount of the claim that Medicare would have paid if you had coverage.

If you have questions regarding how claims are to be paid, please contact Wellmark Blue Cross and Blue Shield of Iowa (1-800-643-9724).

Using CHIP II

The CHIP II plan (Comprehensive Health Insurance Plan) is a comprehensive health care program that covers hospital, medical, surgical, outpatient, and other health care services such as physical therapy.  Coverage is also provided for routine physicals, newborn care (including inoculations, scheduled visits, etc.), well-child checkups, treatment of mental health conditions, treatment of chemical dependency, and prescription drugs.

How an Individual Uses CHIP II

Health care under the CHIP plan may be obtained from any provider you wish.  However, there are advantages to using providers who have contracts with Blue Cross and Blue Shield.

In Iowa, participating providers will accept payment arrangements and file claims for you with Blue Cross and Blue Shield. Payment is made directly to these providers.

Non-participating providers do not have contracts with Blue Cross and Blue Shield.  They do not agree to accept payment arrangements and are not responsible for filing claims for you.  Non-participating providers may charge more for health care than participating providers. Payment is made to you and you are responsible for paying the provider. Non-participating providers can bill you for the difference between what Blue Cross and Blue Shield will pay for a service and what they charge (balance billing).

When you are out-of-state, participating Blue Cross and Blue Shield providers will result in lower out-of-pocket costs for you.  If it is a state that allows balance billing, using a participating Blue Cross and Blue Shield provider should result in a lower balance bill.

In an emergency, if you cannot reasonably reach a participating provider, emergency care received during the course of the emergency will be reimbursed as though the service were received from a participating provider.

Who Can Be Covered

Coverage is provided through Wellmark Blue Cross & Blue Shield of Iowa.  There are four main contract options available:  employee only, employee and spouse, employee and children, and employee and family.

Children may be covered until the age of 26 without tax implications. Coverage for children who are full-time students or disabled can continue as long as they continue in that status.

Domestic partners may also be covered on this policy. See the Domestic Partner Information on the University Benefits Office website for more information.

Dual University of Iowa employed spouses/partners and any children may not double insure each other or dependents under the plans where the University contributes towards the cost of the plans.  This includes the health, dental, and AD&D insurance policies - an individual may only be included once under these policies.

How Much an Individual Pays for Health Care Services

Deductibles.  Insureds pay a deductible and co-insurance on this plan.

This coverage is subject to a Benefit Period Deductible (calendar year).  This is the fixed amount you pay in a benefit period before benefits become available.  This Benefit Period Deductible applies to all services except well-child care (children up to seven years of age) and facility and practitioner services for a newborn's initial hospitalization.  The Benefit Period Deductible is $1,200 per person or $3,600 (maximum) per family.

The family deductible is reached from deductible amounts accumulated on behalf of any combination of members.

Co-insurance.  This is the amount, using a fixed percentage, you pay each time you receive covered services, except for immunizations and/or physician charges for annual physicals.

After you meet the $1,200 deductible, 10% co-insurance applies.  For durable medical equipment, 20% co-insurance applies after the $1,200 deductible.

Out-of-Pocket Maximum (OPM) Expenses for Individuals and Families

The CHIP II Plan provides an annual maximum limit for the OPM expense for both individuals and families.

The annual OPM is $4,200 per person and $8,400 for any other contract (total accumulated amounts paid on any combination of family members).

Once the OPM is reached, the plan pays 100% of covered expenses incurred during the calendar year.

The amount paid by an individual for co-payments, for the treatment or care of infertility, or due to contract limitations are not included in computing the annual out-of-pocket amount.

If a plan member in any contract other than an individual contract (family, employee and children, employee and spouse, etc.) meets the individual OPM, the additional plan member/s continue to pay co-insurance and deductibles until the larger OPM for their contract is met.

The OPM can also be met when no individual plan member meets their individual OPM, but the combination of the out-of-pocket expenses for all the plan members meets the appropriate contract OPM.

Coverage for Prescription Drugs

You have coverage for most prescription drugs and medicines.

There is 10% co-insurance after the $1,200 deductible.  Generic medication will be provided at no cost to the insured.  You will be fully reimbursed for generic medication (0% co‑insurance) and the plan deductible will not apply.

Certain drugs are limited per month, benefit period, or lifetime by drug-specific quantity limitations, or by step therapy requirements or prior authorization.  The limitations are determined by Wellmark based on medical necessity.  For a list of drugs subject to limitations, visit www.wellmark.com or check with your pharmacist or physician.

Care Providers

Provider Category

PARTICIPATING (Blue Cross/Blue Shield)

NON-PARTICIPATING

Description

These providers participate with a Blue Cross and Blue Shield Plan.

These providers do not participate with a Blue Cross and Blue Shield Plan.

Provider

Blue Cross and Blue Shield has contracts with these providers and they agree to accept payment arrangements.

Blue Cross and Blue Shield does not have contracts with these providers and they do not agree to accept payment arrangements.

Claim Settlement

These providers file claims for you.

Claims are settled directly with these providers.

These providers are not responsible for filing claims for you. You may have to file your own claims.

Claims are settled with you, not these providers.

Participating Providers.  These providers accept Blue Cross and Blue Shield payment arrangements.  All hospitals in Iowa are participating providers and over 4,000 physicians in Iowa are also participating providers.

Emergency Services.  If you receive emergency care for covered services and cannot reasonably reach a participating provider, emergency room care received during the course of the emergency will be reimbursed as though the services were received from a participating provider. You will have a $50 co-payment (waived if you are admitted) and the normal co-insurance for your plan.

An emergency can be considered to be a medical condition that a prudent layperson (with an average knowledge of health and medicine) could reasonably expect to result in serious jeopardy to a person’s health in the absence of immediate medical attention.  The emergency services must be provided in an emergency room setting (not an urgent care center or physician’s office).

Providers at The University of Iowa Hospitals and Clinics

When care is provided at The University of Iowa Hospitals and Clinics, the individual and the provider will agree on the role residents will play in the individual's care.  An individual may choose to have all primary health care provided by faculty members.  When an individual is hospitalized, residents and medical students are an integral part of the staff which provides support for treatment by the faculty.

Health Care for Individuals Who Are Away from Iowa

Out-of State.  If you are in a state other than Iowa and require medical care, you may call Wellmark Blue Cross and Blue Shield of Iowa at (800) 810-BLUE (2583) for assistance in locating the closest participating provider in that state.  You can also find providers in other states through the Wellmark website at www.bcbs.com/healthtravel/finder.html.  For covered services received in a state other than Iowa, there are advantages to using providers who participate with the Blue Cross and Blue Shield Plan in that state.

When you are out-of-state, participating Blue Cross and Blue Shield providers will result in lower out-of-pocket costs for you.  If it is a state that allows balance billing, using a participating Blue Cross and Blue Shield provider should result in a lower balance bill.  Balance billing is the practice of billing a patient for the fee amount remaining after the insurer payment and patient co-payment have been made.

Out-of-Country.  If it is necessary to receive covered services in a country other than the United States, it is advisable to contact Blue Cross and Blue Shield for assistance in locating the closest participating provider in that country.

Coordination with Medicare

Payment for care received under any of the retiree health plans by retirees 65 and older assumes that Medicare is your primary health insurance and the University policy is secondary.  The few exceptions to this are described in Section 4:  Filing Claims, under Coordination with Medicare in the CHIP Insurance Certificate.

All claims, except prescription drug claims, should be submitted first to Medicare.  Medicare will determine whether or not this is a covered benefit under their program and will pay based upon that decision. Any amount not covered by Medicare will then be considered under your University Retiree health plan.  Prescriptions can be filed directly with Wellmark.

If you do not have Medicare coverage, the retiree plans will follow the same coordination procedure as stated in the CHIP Insurance Certificate, but you will be responsible to pay the amount of the claim that Medicare would have paid if you had coverage.

If you have questions regarding how claims are to be paid, please contact Wellmark Blue Cross and Blue Shield of Iowa (1-800-643-9724).