Microsoft word - dkc - faq 11-25-12.docx

Door County Kewaunee Consortium FAQs

1. Newly Added FAQ: If a member’s primary care physician is unavailable, the member can
see a partner at their PCP’s office and it will be covered. The claim would need to be billed
with the same taxpayer identification number. That “fill-in” provider can also do any
necessary referrals.
2. When is the next open enrollment period after the initial conversion? 12 or 18 months?
a. UHC will be allowing a “Re-Enrollment” for July of 2013. This will allow members to change between the Navigate and Choice plus POS plan designs. b. The next “open enrollment” will be for July of 2014. 3. On what plan do I need to identify a PCP?
4. Do I have to identify one PCP or can I identify a group? Example, Prevea, Bellin, etc.?
a. You must select an individual provider by family member on the plan. 5. What if I want to change my PCP? How long does that take?
a. Changes made before the 15th of the month will be effective the first of the next month. Changes made after the 15th will be effective the first of the following month. b. You may change every month if you wish 6. Do Dental and Vision plan out of pocket expenses, copays, etc. apply towards my medical
deductible?
a. No. Only medical expenses apply to the medical deductible / Out of pocket. 7. What, if any, voluntary benefits are available to retirees?
a. Please check with your district Administrator 8. Please explain the Value Drug Plan and where I can get $4 options.
a. Wal-Mart and Target advertise these programs and their $4 list is available on their web sites. Shopko does not advertise, but will match price. 9. How often do the prescription drugs under the Value Plan change?
a. UHC does not offer the Value Plan. b. The UHC Traditional Prescription Drug List (PDL) changes are made once per year, in 10. Please explain how the mail order program through UHC works. Do I need to go back to
my doctor to start this process with UHC?
a. You can call your physician and explain the insurance benefits have changed and request a new prescription. If you are out of refills, the provider may request to see you. Otherwise, they will just issue a new prescription. 11. When can I log into myuhc.com? How do I find a provider?
a. You can log into myuhc.com when you have been entered into the UHC eligibility system. b. You will need your unique ID number to log in. c. You can, however, use the physician finder without logging into myuhc.com d. The link for finding a physician is on the right hand side of the page. 12. When is my ID card going to arrive?
a. our ID card will be mailed directly to your home, and should arrive prior to the first of the 13. Does UHC offer direct billing? If so, how do I set it up?
a. Yes, direct billing is offered. b. We will work with the district and M3 to get these individuals set up. 14. If I am having surgery in December, how do I set up the follow up care?
a. If you choose the navigate plan and the follow up care is through your PCP, you will not b. If your follow up care is through a specialist, you will need a referral from your PCP. i. a preauthorization may be needed. I.e. Transplant, experimental treatment, etc. If you are using a network provider, you will have to notify your provider of the insurance change (suggested to do that before the surgery) and they will take care of the rest. ii. If you are using a non-participating provider you are responsible for coordinating your follow up care, and in addition, there is no coverage for out of network and you’d be responsible for 100% of the billed charges. c. If you choose the Choice Plus plan and your provider is in the network, you will only need to let the provider know of the insurance change and they will take care of the rest. d. If you are using a non-par provider, call the number on the back of your ID card as soon as you get it. You will need to choose the selection “notify of an upcoming procedure”. 15. How will the transition of care be handled? For example, what if I am having surgery in
December and need follow up care in January/February after the plan change.
a. If you choose the navigate plan and the follow up care is through your PCP, you will not b. If your follow up care is through a specialist, you will need a referral from your PCP. i. a preauthorization may be needed. I.e. Transplant, experimental treatment, etc. If you are using a network provider, you will have to notify your provider of the insurance change (suggested to do that before the surgery) and they will take care of the rest. ii. If you are using a non-participating provider you are responsible for coordinating your follow up care, and in addition, there is no coverage for out of network and you’d be responsible for 100% of the billed charges. c. If you choose the Choice Plus plan and your provider is in the network, you will only need to let the provider know of the insurance change and they will take care of the rest. d. If you are using a non-par provider, call the number on the back of your ID card as soon as you get it. You will need to choose the selection “notify of an upcoming procedure”. 16. Can my PCP refer me to a specialist in a different system? For instance, my PCP is a
Bellin doctor, but I want my knee surgery done by a Prevea orthopedic surgeon. What if
he/she is unwilling to do so?
a. Yes, referrals can be made from one system to another. If your provider won’t refer you
outside of their system, your options would be to switch PCP’s or Specialists. 17. Will my deductible with WEA transfer over to UHC during the calendar year (this is for the
schools with a July 1 transition).
a. Yes – July 1, 2013 groups, Denmark Gibraltar
b. All districts changing for January 1, 2013 have a calendar year deductible.
18. Is Behavioral Health considered medical care?
a. It would be considered Medical Care.
19. If you need a transplant, where could you go if the UW System is not in network? How is
this handled?
a. Contact UHC at the number on the back of your ID card. Depending on the type of
transplant, you will be directed to the best facility for your care. 20. Are Mayo and Marshfield clinics in network?
a. Mayo is contracted only for the Choice Plus plan.
b. They are not contracted on the Navigate plan.
c. Marshfield is contracted for both plans
i. However you cannot designate a PCP from Marshfield.
21. What is my lifetime maximum?
a. As part of Health Care Reform, There is not a Life Time maximum on the plan. 22. Can I make a change to my flexible spending account allocation with the new plan
becomes active? (for 7/1 transitions)
a. No, changes midyear would not be allowed, per the federal guidelines, a change in plan/carrier is not considered a qualify event. 23. Who is considered a Primary Care Provider (PCP)? Can an NP or PA be considered a
PCP? Can an OB/GYN, Pediatrician, and Family Practice? Internal Med?
a. Primary care is: Internal Medicine, Pediatrician, Family Practice, and General Practice. b. You cannot select an OB/GYN, NP or PA as your primary care doctor. c. You would select the MD/DO that the PA or NP practice under for you PCP. d. OB/GYN does not require a referral. 24. Can a Chiropractor refer me into specialty care?
a. On the Navigate Plan, no, only your PCP can refer you. b. On the Choice Plus Plan, referrals are not needed. 25. In regards to Navigate, are chiropractic visits subject to a copay or
deductible/coinsurance?
a. Chiropractic visits would be a $10.00 copay. 26. What does “May Be Excluded” mean in regards to the prescription drug list coverage?
a. These medications are not covered under your plan. b. These are medications that have considerations for other groups, but since this is a shared list with much of UHC’s membership, they are listed here. c. However, your plan ALSO INCLUDES: Prilosec OTC, Zaditor, Omeprazole, Loratadine,
and Alaway under tier one that is not covered by other UHC Groups
How do I find a network pharmacy?
Here is a link:
https://www.optumrx.com/clientpharmacy/pharmacylocatorclient.asp?var=PCCFZN&infoid=PCCF
ZN&page=insert&par
27. What if my doctor leaves the network? Do I need to identify another PCP? How do I notify
UHC?
a. If you are on the Navigate Plan and your provider leaves the network, you will need to b. Contact UHC using the number on the back of the ID card to make the changes. Changes made before the 15th of the month will be effective the first of the next month. Changes made after the 15th will be effective the first of the following month. 28. Explain the logic behind the need for the PCP referral.
a. The idea behind the Navigate Plan is to have you develop a relationship with your PCP. By requiring referrals, your PCP will be aware of all of your care and can help you coordinate and manage your care more effectively. 29. Do I physically need to go see my PCP EVERY time I need to see a specialist?
a. Depending on the relationship you have with your PCP, it may not be necessary to physically see them before a referral. However, if you haven’t seen them recently, or if they feel they can handle your care, they may request to see you prior to making a referral. 30. Who’s responsibility is it to make sure the referral is to an in network provider?
a. Your PCP will be responsible for ensuring the provider they refer you to is in the network. 31. How long does the referral process take? In other words, if I need a referral right away,
how long does it take to communicate that information?
a. Referrals are done electronically, and are immediately viewable by the Specialist. 32. Do you use our Social Security number?
a. No, you will be assigned a unique ID number. 33. What services do not require a referral?
a. OB/GYN b. Mental Health/Substance Abuse c. Chiropractor d. Routine refractive eye exams e. Emergency/urgent g. Inpatient consulting physicians h. Lab tests. 34. Web sites:
a. Medical – www.myuhc.com b. Networks: i. United Healthcare Navigate/Navigate Balanced Dental - myuhcdental.com Network: Dental Options PPO Mental Health/Substance Abuse – liveandworkwell.com 1. (Access code until you can be a registered user is UNITED). 35. Pre-enrollment phone number:
b. You must identify yourself as being from the Door/Kewaunee School Co-op.
36. We have former employees who are currently on long term disability through WEA and
their premium is waived. Do these individuals remain on WEA insurance or do they make
the switch to UHC? Also, if they are switching to UHC, which plan do they use?
a. UHC will be providing the waiver of premium option as did WEA. The member will roll onto the same plan as the district with UHC. 37. Do we have a contact number at UHC for questions regarding health insurance coverage?
a. For General questions, the members were provided with 866-873-3903. Once members have their ID cards, they can call member services on the back of the card 38. Do we have a contact number at UHC for questions regarding the supplemental
coverage?
a. The 800# can help on dental and vision 39. When are applications for the supplemental insurance due? Should they be submitted
directly to UHC or collected by the district?
a. Each group is setting their own deadlines so check with your district office. It is recommended having them due no later than 12/14. The applications should be collected by the district and then can be mailed to Samantha at UHC. 40. I have the names of several providers that employees use to submit to UHC to attempt to
get into the network. Where and when should I submit those?
41. Orthodontist- My daughter has had braces since last January. We have another 6-12
months to go. Our orthodontist is not in network with United Health. What do I do? I owe
that office. I've been paying 50% each month as WEA matched that. I can't go somewhere
else as I'm under signed contract with that office.
a. The plan has 50% coverage for ortho at both in and out of network providers so you can continue to see the current provider, which is what 99.9% of members in this situation
do. The only difference between in and out of network providers is that the in network
dentists are required to comply with our contracted rates while out of network dentists are
not, so the cost of coverage at an out of network provider may be slightly more
expensive. Also, with the transition to UHC you will get a whole new $2,000 lifetime ortho
maximum to use toward the cost of the treatment.
42. Just switched dentists in August. My new dentist and my old dentist are not in network
for United Health. I did a 15 mile search from my home and nothing comes up.
a. The plan covers in and out of network providers at the same coinsurance level so you are not required to use an in network provider. You are able to go to any dentist that you want to go to however; UHC will not pay more than the usual and customary charges. Example: You may go to a dentist who is not in the UHC network for a crown and be charged $1,000. If you went to a dentist who was in the network the charge might be $800 and you would then have more money to use for other dental procedures ($1,300 - 800 = $500 or $1,300 - 1,000 = $300). Also, if your dentist is not in the network, you may have to pay the amount that is above the usual and customary amount charged for the procedure. Additionally, we are attempting to recruit additional providers in the Door County area to join our dental network. (This is the same as how the plan operates under WEA today) 43. How does the $10 co pay work on the medical plan?
a. Your office visit will have a $10 co pay, the remainder of the visit/charges will be paid at 44. We have a member that has a daughter, age 16, that has an infant child. Should that baby
be listed as “NB” on the enrollment?
a. YES – they should be listed as NB or Child b. The NB child can remain on the plan until the dependant daughter turns age 18 45. Question on referrals - Example: A member on Navigate has a daughter in Iowa on their
insurance. The daughter needs to see a doctor because she suspects she has strep
throat. Would she need to call her PCP to get a referral? What if she doesn’t need to see a
specialist down there? Does the PCP refer to a non-specialist if it’s out of the area?
a. YES – you need to see a PCP to a non-specialist out of the area. 46. Vision Insurance: Will the re-enrollment in July be available for vision insurance not only
for July 2014, but for July 2013 as well?
47. Is the D/K Co-op considered one employer? I had asked the question earlier wondering
about one of our employees with a spouse that works at Southern Door. I asked if they
could switch from our health plan to Southern Door’s or vice-versa. I was told no - that it
would have to be an open enrollment or they would have to have a qualifying event to
switch. However, currently health coverage does not require an involuntary loss of
coverage in order to switch. As far as I knew, only dental required an involuntary loss of
coverage to switch. So I am wondering why a switch would have to occur during an open
enrollment period or have a qualifying event.
a. No, a member will have to have a qualifying event, or open enrollment 48. We have one employee that has a handicapped dependent child in a treatment foster care
placement in Green Bay. Is there anything different we need to list on her enrollment
data?
49. I asked this question before, but others may be interested in the response for their
enrollment information. I asked if we really had to use the actual hire (or start) date of the
employee.
a. “As long as the date is on or prior to the effective date for coverage, you may use any date. If it would make things easier, you can use 01/01/2013 for the date of hire.” Concerns
1. Explain the Door County Kewaunee Consortium. Why it exists. How long it has been
around.
a. The Door Kewaunee Cooperatives have been together for many years under the WEA. It was only September of 2012 that the 9 school districts became a cooperative under the State of Wisconsin Statutes. This recognition/commitment under the State Statutes allowed other insurance carriers to also price the 9 districts as a whole. 2. For the districts participating in Navigate, please provide a detailed description between
Navigate and Choice Plus.
a. Please refer to Power Point Presentation for detailed description. b. Navigate plan requires members to choose a primary care provider (PCP) and does not allow members to self navigate to specialists. A referral is necessary to have the care covered under the plan. c. Choice Plus works just as your current plan does today, no referral is necessary 3. On the Navigate Plan, please describe the “why” behind the need to identify a PCP where
the policyholder is domiciled even for dependents who live out of state.
a. You, the policy holder own the contract, so the governing rules of where primary care CONSIDERATIONS
1. Please include information in the packets on UHC’s specialty discounts, including fitness
memberships.
a. Additional information will be provided after the first of the year. 2. Please explain the drug tiers a little more effectively.
a. Refer to Power Point slides for a clear explanation

Source: http://www.sturbay.k12.wi.us/faculty/CECKERS/Navigate%20FAQs.pdf