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2019-2020 Student Health Plan provided by Saudi Arabian Cultural Mission (SACM) Student Guide 19COL3934 Version Date: October 2, 2019 INTEGRITY Good health is essential to your academic success. COMPASSION UnitedHealthcare remains committed to supporting students to ensure they can achieve their academic goals, and we are uniquely qualified to meet that commitment. RELATIONSHIPS INNOVATION PERFORMANCE Our nationwide networks are robust and highly competitive, our innovative eligibility and administrative systems are built specifically to support student health benefit plans and our employees are dedicated to the needs of the schools and their students. Contents Within this guide, you will find valuable information about the services available to you. Please note that Medical and Dental services are separate from each other. We recommend you become familiar with this guide and the corresponding resources for medical and dental to learn about your plan and how to use your benefits. UHC at a Glance Welcome to UHCSR Your Medical Coverage – PPO Plan My Account and Access your Medical ID Card Find a Medical Health Care Provider Which provider should I see? Definitions Global Emergency Services Telemedicine by HealthiestYou Hospitalization Pre-Admission Notification Submit a Claim for Member Reimbursement How to reach UHC for Medical Information Your Dental Coverage Access your Dental ID Card How to Find a Dental Health Care Provider How to reach UHC for Dental Information Your Vision Coverage ID Card for Vision Benefits How to Find a Vision Care Provider How to reach UHC for Vision Information 3 4 5 8 9 9 10 12 12 13 14 15 16 17 17 17 18 19 19 19 UHC at a Glance Where to find helpful information On your home page, www.uhcsr.com/SACM: Find Providers ◦ Medical ◦ Behavioral Health ◦ Dental ◦ Vision For customer service, please call 1-866-808-8461 Find Pharmacy Plan Description ◦ Details on your medical and dental benefits ◦ SACM Student Guide Helpful Information ◦ Create Account Guide Create/log in to My Account Download the Mobile App 24 hours a day, 7 days a week On your My Account page: Helpful Links Network Medical Provider Search Dental Provider Search View Current Coverage View Personal Information View/Print/Download/Request ID Card View Claims Information Submit Accident Details Personal Representative Appointment (for authorizing someone to act on your behalf in matters of your benefit plan) Links to Value Added Benefits ◦ ◦ ◦ ◦ Your home page is: www.uhcsr.com/SACM Global Emergency Services HealthiestYou UHC Dental UHC Vision Message Center ◦ My Messages ◦ My Documents (See page 8 for details about creating My Account) 3 Use it to access your benefit information, including locating a provider, viewing claims, and other features of your My Account page. Welcome to UnitedHealthcare StudentResources (UHCSR) UHCSR is the dedicated student health division of UnitedHealthcare (UHC). UHCSR will be your first point of contact for all questions. Below is where to find helpful information. Provider Search Benefit Information You can search for health care preferred providers online at www.uhcsr.com/SACM or on your mobile device with our free UHCSR Mobile App. You can find your Student Guide and other helpful information regarding the available services as well as general health information and FAQs at www.uhcsr.com/SACM. Account Information Log into My Account at www.uhcsr.com/SACM. From there you can download your medical ID card, access medical claims information, see messages sent to you and access other helpful information. 4 Your Medical Coverage – PPO Plan A generous health benefit plan is provided by SACM for its students and their dependents. SACM students are covered at 100% for Preferred Provider In-Network care. The UHC network is one of America’s largest health care networks, with over 1.7 million network providers. For questions pertaining to your medical benefits, call Customer Service at 1-866-808-8461. Your medical plan includes: Doctor office visits and preventive care (routine physicals, immunizations, cancer screenings) Diagnostic lab and radiology tests Vision care Pharmacy coverage Inpatient and outpatient care Mental health services Home health care Maternity care Short-term rehabilitation (physical, occupational and speech therapy) Emergency and urgent care Your full summary of benefits is listed below. The benefits are provided by your plan sponsor (SACM) and are subject to change by SACM. A complete description of your benefits and any limitations and exclusions are provided in the SACM Benefits Booklet, Plan Number 2019-1965-1. Eligibility Provisions Students Diplomat or Staff Dependents Plan Features Maximum Benefit Deductible Coinsurance Notes on your Benefits Plan Any sponsored Saudi national enrolled in a scholarly program in the United States pursuant to a valid student visa issued by the United States Any sponsored Saudi national in the United States on a valid visa serving as a Diplomat or Staff of the Saudi Government is eligible to be enrolled in the plan. Dependents of insureds that are in an Eligible Class are also eligible to be covered under the plan. Preferred Provider Out‐of‐Network Provider No Overall Maximum Dollar Limit (Per Covered Person, Per Plan Year) $0 ( Per Covered Person, Per Plan Year ) $10,000 ( Per Covered Person, Per Plan Year ) 100% except as noted below 20% except as noted below The Preferred Provider network for this Plan is UnitedHealthcare Choice Plus PPO. If care is received from a Preferred Provider any Covered Medical Expenses will be paid at the Preferred Provider level of Benefits. If a Preferred Provider is not available in the Network Area, Benefits will be paid at the level of Benefits shown as Preferred Provider Benefits. If the Covered Medical Expense is incurred due to a Medical Emergency, Benefits will be paid at the Preferred Provider level of Benefits. Covered Medical Expense incurred at a Preferred Provider facility by an Out‐of‐Network Provider will be paid at the Preferred Provider level of Benefits. In all other situations, reduced or lower Benefits will be provided when an Out‐of‐Network provider is used. Benefits will be reimbursed at one hundred percent (100%) of billed charges under the following circumstances: 1) All Covered Medical Expenses for services rendered in Saudi Arabia; and 2) Covered Medical Expenses when due to a Medical Emergency occurring in any country outside of the United States. The Plan Deductible will not apply. The Benefits payable are as defined in and subject to all provisions of the Benefits Booklet and any endorsements thereto. Benefits are subject to the Plan Maximum Benefit unless otherwise specifically stated. Benefits will be paid up to the maximum Benefit for each service as scheduled below. All Benefit maximums are combined Preferred Provider and Out‐of‐Network unless otherwise specifically stated. Plan Payments Inpatient Preferred Provider Out‐of‐Network Provider Room & Board: Preferred Allowance Usual and Customary Charges (Includes guest bed and meal trays for adult accompanying a minor while confined as an Inpatient.) Intensive Care: Preferred Allowance Usual and Customary Charges Hospital Miscellaneous Expense: Preferred Allowance Usual and Customary Charges Routine Newborn Care: Paid as any other Sickness Paid as any other Sickness Surgery: Preferred Allowance Usual and Customary Charges (If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 50% of all subsequent procedure.) Assistant Surgeon Fees: Preferred Allowance Usual and Customary Charges Anesthetist Services: Preferred Allowance Usual and Customary Charges Registered Nurse’s Services: Preferred Allowance Usual and Customary Charges Physician’s Visits: Preferred Allowance Usual and Customary Charges Pre‐admission Testing: Preferred Allowance Usual and Customary Charges 5 Outpatient Preferred Provider Out‐of‐Network Provider Surgery: Preferred Allowance Usual and Customary Charges (If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 50% of all subsequent procedure.) Day Surgery Miscellaneous: Preferred Allowance Usual and Customary Charges Assistant Surgeon Fees: Preferred Allowance Usual and Customary Charges Anesthetist Services: Preferred Allowance Usual and Customary Charges Physician’s Visits: Preferred Allowance Usual and Customary Charges Physiotherapy: Preferred Allowance Usual and Customary Charges (12 visits maximum (Per Plan Year)) Medical Emergency Expenses: Preferred Allowance Usual and Customary Charges $100 Copay per visit $100 Deductible per visit (The Copay/per visit Deductible will be waived if admitted to the Hospital.) (Benefits include the use of the Emergency Room for a non‐emergency Injury or Sickness.) Diagnostic X‐ray Services: Preferred Allowance Usual and Customary Charges Radiation Therapy: Preferred Allowance Usual and Customary Charges Laboratory Procedures: Preferred Allowance Usual and Customary Charges Tests & Procedures: Preferred Allowance Usual and Customary Charges Injections: Preferred Allowance Usual and Customary Charges Chemotherapy: Preferred Allowance Usual and Customary Charges Prescription Drugs: UnitedHealthcare Pharmacy (UHCP) Usual and Customary Charges Ancillary Charge applies when $0 Copay per prescription for Tier 1 prescription is dispensed from a $0 Copay per prescription for Tier 2 higher tier at the Covered Person’s $0 Copay per prescription for Tier 3 request and a chemically equivalent up to a 31 day supply per prescription plus any prescription drug is available at a Ancillary Charge lower tier. (Mail order Prescription Drugs through UHCP with a $0 Copay per prescription plus any Ancillary Charge up to a 90 day supply per prescription.) Other Preferred Provider Out‐of‐Network Provider Ambulance Services: Preferred Allowance Usual and Customary Charges Durable Medical Equipment: Preferred Allowance Usual and Customary Charges Consultant Physician Fees: Preferred Allowance Usual and Customary Charges Dental Treatment: Preferred Allowance Usual and Customary Charges (Includes benefits for Injury to Sound, Natural Teeth, and treatment of cleft lip and cleft palate only.) Mental Illness Treatment: Paid as any other Sickness Paid as any other Sickness Substance Use Disorder Treatment: Paid as any other Sickness Paid as any other Sickness Maternity: Paid as any other Sickness Paid as any other Sickness Complications of Pregnancy: Paid as any other Sickness Paid as any other Sickness Preventive Care Services: Preferred Allowance Usual and Customary Charges (Routine Children Physicals: Includes all services given in connection with the exam. Limited to 7 exams in the first 12 months of life, 3 exams in the second 12 months of life, 3 exams in the third 12 months of life, and 1 exam per calendar year thereafter up to age 18.) (Routine Adult Physical Exams: Includes all services given in connection with the exam. Limited to 1 exam per calendar year for adults age 18 and over.) (Routine Gynecological Exams: Includes all services given in connection with the exam. Limited to 1 exam and pap smear per calendar year.) (Mammograms: Unlimited) (Prostate Specific Antigen (PSA): Limited to 1 PSA test per calendar year for males age 40 and over.) (Digital Rectal Exam (DRE): Limited to 1 DRE per calendar year for males age 40 and over.) (Cancer Screening: Limited to 1 flexible sigmoidoscopy and double barium contrast every 5 years. Limited to 1 colonoscopy every 10 years for adults age 50 and over.) (Fecal Occult Blood Test: Limited to 1 per calendar year.) (Testing for Tuberculosis.) Reconstructive Breast Surgery Paid as any other Sickness Paid as any other Sickness Following Mastectomy: Diabetes Services: Paid as any other Sickness Paid as any other Sickness Home Health Care: Preferred Allowance Usual and Customary Charges (Unlimited visits per Policy Year.) Hospice Care: Preferred Allowance Usual and Customary Charges (Inpatient: 30 days lifetime maximum. Outpatient: $10,000 lifetime maximum.) 6 Other (continued) Preferred Provider Inpatient Rehabilitation Facility: Preferred Allowance Skilled Nursing Facility: Preferred Allowance Urgent Care Center: Preferred Allowance Hospital Outpatient Facility or Clinic: Preferred Allowance Approved Clinical Trials: Paid as any other Sickness Transplantation Services: Paid as any other Sickness Acupuncture in Lieu of Anesthesia: Paid as any other Sickness Hearing Aids: Preferred Allowance ($3,500 maximum (Per Plan Year). A written prescription is required). Infertility Services: Preferred Allowance Preferred Allowance Medical Foods: (A written prescription is required.) Ostomy Supplies: Preferred Allowance TMJ Disorder: Preferred Allowance ($5,000 maximum (Per Plan Year)) Repatriation: Benefits provided by UnitedHealthcare Global or reimbursed by SACM Medical Evacuation: Benefits provided by UnitedHealthcare Global Other: Note Below Out‐of‐Network Provider Usual and Customary Charges Usual and Customary Charges Usual and Customary Charges Usual and Customary Charges Paid as any other Sickness Paid as any other Sickness Paid as any other Sickness Usual and Customary Charges Usual and Customary Charges Usual and Customary Charges Usual and Customary Charges Usual and Customary Charges Benefits provided by UnitedHealthcare Global or reimbursed by SACM Benefits provided by UnitedHealthcare Global Note Below Spinal Disorder Treatment: Preferred Allowance / Usual and Customary Charges – (Caused by or related a biochemical or nerve disorders of the spine. Unlimited visits per Plan Year.) Ear Piercing provided in the Physician’s office for Females age 10 and under: Preferred Allowance / Usual and Customary Charges. Treatment for Congenital Defects and Pre‐mature Born Babies: Preferred Allowance / Usual and Customary Charges. Braille Machines: Preferred Allowance / Usual and Customary Charges ($700 maximum per Plan Year.). Sickle Cell Anemia Testing During Pregnancy: Preferred Allowance/Usual and Customary Charges. Obesity Treatment: Paid as any other Sickness / Paid as any other sickness. Routine Hearing Exams: Preferred Allowance (Includes one audiometric routine exam per Plan Year.) Usual and Customary Charges 7 Sign up for My Account and Access your Medical ID Card New medical ID cards will be mailed in August 2019 to the U.S. mailing address that we have on file. If you’re a new member, you should receive your medical card sometime in January 2020. You can visit www.uhcsr.com/SACM to create your MyAccount and download an electronic copy of your UHCSR medical card. You may also download our UHCSR Mobile App from your App Provider so you can have your account information and medical ID card for you and your dependents (if applicable) readily available on your Smart Phone. Once you’ve created your My Account, just log in with your user name and password at www.uhcsr.com/SACM and begin to access your account online, at your own convenience. Creating your My Account is easy! Visit www.uhcsr.com/SACM and click the Create an Account link Create your account today and: • View benefits and coverage details Follow the onscreen prompts – you’ll need your First and Last Name, Date of Birth and your Saudi National ID. • View/print/fax your medical ID card • Review information about your dental plan Create your user name. Your user name must contain 6 – 30 alphanumeric characters. Verify your email address and submit. • Review Action Center alerts and your messages • Check Claim status and Explanations of Benefits (EOB) You will receive a return email with a pin that you will use to verify your account and create a password. Your password must have 8-12 characters and include at least three of the following: an uppercase character, a lowercase character, a numeric character (0-9), and a special character (e.g., *, ~, $, etc.). • Review claims letters • Search for a preferred provider • Provide accident details or Personal Representative Appointment • Review your personal information – if we don’t have your U. S. mailing address, be sure to update it in the SACM Database, through the Ministry of Higher Education student portal/ Safeer as soon as possible. 8 How to Find a Medical Health Care Provider Choose a UnitedHealthcare medical provider to help maximize health care dollars and lower out-of-pocket costs. Use the UHCSR Mobile App or go to www.uhcsr.com/SACM and click “Find Providers”. Or call Customer Service at 866-808-8461. 1. Access your SACM Welcome page at www.uhcsr.com/SACM 2. In the “Find Providers” section click the Medical – UHC Choice Plus link 3. Click Change Location and specify a ZIP code or city/state to narrow down the location. Click OK. 4. In the Search box, specify Doctor Name or Specialty, Facility Name, Clinic Name, or Medical Group Name. Click SEARCH. • You may also click the Find Health Care by Category buttons below the Search box to search by People, Places, Tests and Imaging, Services and Treatments or Care by Condition. 5. Follow the prompts to further refine your search criteria. • The search results will indicate the providers’ address, phone number and other details. Which provider should I see? Sometimes it may be difficult to decide if a sudden illness or injury needs immediate emergency care. Choosing the right health setting – Primary Care Physician, Urgent Care, or Emergency Room is important; knowing which provider to see, depending on the medical situation, can save you time and money. Primary Care Physician When you or a loved one is hurt, you want the best care. Your primary care physician knows you and your health history. He or she can access your medical records. And, he or she can provide you follow-up care or refer you to specialists. If it’s not urgent, it’s usually best to go to your own physician’s office. Urgent Care Sometimes you may need care fast. But, your Primary Care Physician may be unavailable. You may want to try an urgent care center. They can treat many minor ailments. Chances are, you won’t have to wait as long as at an emergency room. You may pay less, too. An urgent care center can help with: • Sprains & Strains • Minor broken bones (example: finger) • Minor infections • Small cuts • Sore throats • Rashes Emergency Rooms You may be tempted to go to an emergency room (ER). But, this may not be the best choice. At the ER, true emergencies are treated first. Other cases must wait–sometimes for hours. And, it may cost you more. Go to an ER for: • Heavy bleeding • Large open wounds • Sudden change in vision • Chest pain • Sudden weakness or trouble talking • Major burns • Severe head and spinal injuries • Difficulty breathing • Major broken bones 9 Definitions Below, you will find a definition of what’s considered a medical emergency for the purpose of plan benefits in addition to other relevant terms that will help you navigate your benefit plan. ANCILLARY CHARGE means a charge, in addition to the Copayment and/or Coinsurance, that the Covered Person is required to pay when a covered Prescription Drug Product is dispensed at the Covered Person’s or the Physician’s request, when a Chemically Equivalent Prescription Drug Product is available on a lower tier. For Prescription Drug Products from Network Pharmacies, the Ancillary Charge is calculated as the difference between the Prescription Drug Cost or MAC list price for Network Pharmacies for the Prescription Drug Product on the higher tier, and the Prescription Drug Cost or MAC list price of the Chemically Equivalent Prescription Drug Product available on the lower tier. BENEFITS means Plan payments for Covered Medical Expenses, subject to the terms and conditions of the Plan and any Addendums and/or Amendments. CLAIMS ADMINISTRATOR OR ADMINISTRATOR means United HealthCare Services, Inc., and its affiliates, which provide certain claim administration services for the Plan. COINSURANCE means the percentage of Covered Medical Expenses that you must pay. COPAY/COPAYMENT means a specified dollar amount that the Covered Person is required to pay for certain Covered Medical Expenses. COVERED MEDICAL EXPENSES means reasonable charges which are: 1) not in excess of Usual and Customary Charges; 2) not in excess of the Preferred Allowance when the Plan includes Preferred Provider Benefits and the charges are received from a Preferred Provider; 3) not in excess of the maximum Benefit amount payable per service as specified in the Schedule of Benefits; 4) made for services and supplies not excluded under the Plan; 5) made for services and supplies which are a Medical Necessity; 6) made for services included in the Schedule of Benefits; and 7) in excess of the amount stated as a Deductible, if any. DEDUCTIBLE means if an amount is stated in the Schedule of Benefits or any other section of this Plan as a deductible, it shall mean an amount to be subtracted from the amount or amounts otherwise payable as Covered Medical Expenses before payment of any Benefit is made. The deductible will apply as specified in the Schedule of Benefits. ELECTIVE SURGERY OR ELECTIVE TREATMENT means those health care services or supplies that do not meet the health care need for a Sickness or Injury. Elective surgery or elective treatment includes any service, treatment or supplies that: 1) are deemed by the Plan Sponsor to be research or experimental; or 2) are not recognized and generally accepted medical practices in the United States. HOSPITAL means a licensed or properly accredited general hospital which: 1) is open at all times; 2) is operated primarily and continuously for the treatment of and surgery for sick and injured persons as inpatients; 3) is under the supervision of a staff of one or more legally qualified Physicians available at all times; 4) continuously provides on the premises 24 hour nursing service by Registered Nurses; 5) provides organized facilities for diagnosis and major surgery on the premises; and 6) is not primarily a clinic, nursing, rest or convalescent home. Hospital also means a licensed alcohol and drug abuse rehabilitation facility and a mental hospital. Alcohol rehabilitation facilities and mental hospitals are not required to provide organized facilities for major surgery on the premises or on a prearranged basis. INJURY means bodily injury which is all of the following: 1) directly and independently caused by specific accidental contact with another body or object. 2) unrelated to any pathological, functional, or structural disorder. 3) a source of loss. 4) treated by a Physician within 30 days after the date of accident. 5) sustained while the Covered Person is covered under this Plan. 10 All injuries sustained in one accident, including all related conditions and recurrent symptoms of these injuries will be considered one injury. Injury does not include loss which results wholly or in part, directly or indirectly, from disease or other bodily infirmity. Covered Medical Expenses incurred as a result of an injury that occurred prior to this Plan’s Effective Date will be considered a Sickness under this Plan. MEDICAL EMERGENCY means the occurrence of a sudden, serious and unexpected Sickness or Injury. In the absence of immediate medical attention, a reasonable person could believe this condition would result in any of the following: 1) Death. 2) Placement of the Covered Person’s health in jeopardy. 3) Serious impairment of bodily functions. 4) Serious dysfunction of any body organ or part. 5) In the case of a pregnant woman, serious jeopardy to the health of the fetus. Expenses incurred for “Medical Emergency” will be paid only for Sickness or Injury which fulfills the above conditions. These expenses will not be paid for minor Injuries or minor Sicknesses. NETWORK AREA means the 50 mile radius around the local school campus the Covered Person is attending. OUT OF NETWORK means those providers who have not agreed to any prearranged fee schedules. Covered Persons may incur significant out-of-pocket expenses with these providers. Charges in excess of the amount paid by the Plan are the Covered Person’s responsibility. PLAN means The Saudi Arabian Cultural Mission Student Health Plan. PLAN ADMINISTRATOR means The Saudi Arabian Cultural Mission or its designee. PLAN SPONSOR means The Saudi Arabian Cultural Mission. PREFERRED PROVIDER means the Physicians, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices. The Plan offers the network of Preferred Providers which is known as: UnitedHealthcare Choice Plus PPO. The availability of specific providers is subject to change without notice. Covered Persons should always confirm that a Preferred Provider is participating at the time services are required by calling the Administrator at 1-800-767-0700 and/or by asking the provider when making an appointment for services. SICKNESS means sickness or disease of the Covered Person which causes loss while the Covered Person is covered under this Plan. All related conditions and recurrent symptoms of the same or a similar condition will be considered one sickness. Covered Medical Expenses incurred as a result of an Injury that occurred prior to this Plan’s Effective Date will be considered a sickness under this Plan. URGENT CARE CENTER means a facility that provides treatment required to prevent serious deterioration of the Covered Person’s health as a result of an unforeseen Sickness, Injury, or the onset of acute or severe symptoms. USUAL AND CUSTOMARY CHARGES means the lesser of the actual charge or a reasonable charge which is: 1) usual and customary when compared with the charges made for similar services and supplies; and 2) made to persons having similar medical conditions in the locality where service is rendered. The Administrator uses data from FAIR Health, Inc. and Data iSight to determine Usual and Customary Charges. Usual and Customary Charges determined using data from FAIR Health, Inc. will be calculated at the 75th percentile. No payment will be made under this Plan for any expenses incurred which in the judgment of the Administrator are in excess of Usual and Customary Charges. 11 Global Emergency Services Your global emergency services benefit through UnitedHealthcare Global is a comprehensive program that provides 24/7 medical and travel assistance to participants who call their Emergency Response Center. A multilingual case manager takes the call and immediately provides assistance. Participants can even call the Emergency Response Center before traveling to get a pre-trip destination report that covers subjects like health and security risks, immunization and vaccination recommendations, crime, culture, weather, and so much more. Foreign national students studying in the US – You’re eligible for services for the duration of your studies while traveling 100 miles or more from your campus in the US and traveling outside of your home country. You have access to doctors, hospitals, pharmacies, and certain other services when faced with a travel or medical emergency while outside the US. One phone call to UnitedHealthcare Global connects you to: Medical Assistance Services Medical Evacuation and Repatriation Services Security and Natural Disaster Evacuation Services Worldwide Destination Intelligence Travel Assistance Services Experienced crisis management professionals A global network of over 41,000 pre-qualified medical providers Please visit www.uhcsr.com/UHCGlobal for the UnitedHealthcare Global brochure which includes service descriptions and program conditions and limitations. To access services, call or email: Toll-free within the US: 1-877-294-2038 Collect outside the US: 1-410-453-6330 Email: email@example.com Telehealth with HealthiestYou We’ve partnered with HealthiestYou to provide you with round-the-clock access to board-certified physicians. SACM members* can connect with a physician via phone and/or video chat** using this nationwide telehealth service. During a physician consult, you will be able to speak to a physician for diagnosis and treatment of many different acute illnesses. HealthiestYou also offers notifications via smart phone app – students may receive a notification when they arrive at an Emergency Room or Urgent Care Center. This notification will serve to remind you of your telehealth benefit that allows you to speak to a doctor without having to sit in a waiting room. *When services are obtained during the policy effective dates. Non-SACM members will be charged a $40 consultation fee. **Telephone services and/or video chat availability is determined by state requirements. To access services: Toll-free within the US: 1-855-777-4856 Web: www.telehealth4sacm.com 12 Hospitalization Pre-Admission Notification UnitedHealthcare should be notified of all Hospital admissions: • Pre-notification of medical non-emergency hospitalizations: The patient, Physician or Hospital should call the phone number on the covered person’s ID card at least five working days prior to a planned admission. • Notification of medical emergency hospitalizations: The patient, patient’s representative, Physician or Hospital should call the phone number on the covered person’s ID card within two working days of an emergency admission. UnitedHealthcare is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m. C.S.T., Monday through Friday. Calls may be left on the Customer Service Department’s voice mail after hours. Note: Failure to follow the notification procedures will not affect benefits otherwise payable under the policy; however, pre-notification is not a guarantee that benefits will be paid. 13 Submit a Claim for Member Reimbursement Use this procedure to be reimbursed for medical claims you paid to out-of-network providers in the U.S. or for care outside the U.S.: • A claim form is not required. • All documentation submitted must be legible. • Provide a copy of the front and back of your ID card as well as the patient information if different than the primary insured member. • Medical claims bills must include Provider name, address and phone number, diagnosis code (nature of illness), procedure code (service performed), service date and cost. • For prescription claims, provide your receipt or computer printout from the Pharmacy which includes patient name, doctors name, medicine name, date dispensed, quantity and purchase price. • Valid proof of payment must also be submitted with your claims, otherwise there may be a delay in claim reimbursement. See below for a list of requirements. • Mail the claim to the address below. Be sure to keep a copy for your records. Valid Proof of Payment: Please submit the following as proof of payment. • Medical bills and prescriptions paid in cash: ◦ UHCSR will call the provider of services to verify all cash payments • Medical bills and prescriptions paid by check: ◦ Copy of front and back of cancelled check • Medical bills and prescriptions paid with a credit card: ◦ Copy of the credit card statement showing payment for the services billed Mail Claims to the Claims Administrator: UnitedHealthcare StudentResources P.O. Box 809025 Dallas, TX 75380-9025 If you have any questions, please contact our Customer Service Department: Phone: eMail: 866-808-8461 or ATT Access Code + 866-808-8335 (outside the U.S.) firstname.lastname@example.org 14 How to reach UHC for Medical Information Our live Customer Service Representatives can be reached 24 hours a day, 7 days a week. Customer Service may also be contacted via e-mail for claims at email@example.com or for general Customer Service inquiries at firstname.lastname@example.org. Our e-mail team responds to all inquiries within two business days. Correspondence received during business hours is replied to within 3 hours or less. Customer Service 1-866-808-8461 ATT Access Code + 866-808-8335 (from outside the U.S.) Mailing Address UnitedHealthcare StudentResources P.O. Box 809025 Dallas, TX 75380-9025 Email email@example.com firstname.lastname@example.org Website www.uhcsr.com/SACM 15 Welcome to UHC Dental A generous dental benefit plan is provided by SACM for its students and their dependents for care sought inside the U.S. with In-Network providers. SACM students are covered at 100% for In-Network care. The UnitedHealthcare Dental network has over 385,000 dental access points for our members. Your dental plan includes: Plan Features Deductible $0/$0 Annual Max $2000 Lifetime Ortho Max $2000 Plan Payments Diagnostic Service Preferred Provider Periodic Oral Evaluation 100% Radiographs 100% Lab and Other Diagnostic Tests 100% Preventive Services Preferred Provider Dental Prophylaxis (Cleaning) 100% Fluoride Treatment 100% Sealants 100% Space Maintainers 100% Basic Services Preferred Provider Restorations (Amalgams or Composite) 100% Emergency Treatment/General Services 100% Simple Extractions 100% Oral Surgery (incl. surgical extractions) 100% Periodontics & Endodontics 100% Major Services Preferred Provider Inlays/Onlays/Crowns 100% Dentures and Removable Prosthetics 100% Fixed Partial Dentures (Bridges) 100% Orthodontic Services Preferred Provider Orthodontia 100% Account Information Log into www.myuhc to download your dental ID card, access dental claims information, and access other helpful information. Did you know? Note: There is no out of network dental benefit. 16 When SACM members receive dental services from a network dentist, the dentist submits the claim and is paid directly by UHC Dental. Access your Dental ID Card Your benefit plan includes Dental benefits administered by UHC Dental. If you are a new SACM member, you will receive a dental ID card in the mail. Continuously enrolled SACM members will use the dental ID card initially sent with their plan materials. If you do not receive your Dental ID Card in the mail, please review your Personal Information in your UHCSR My Account to verify the information we have in our system. If we don’t have your U. S. mailing address, be sure to update it in the SACM Database, through the Ministry of Higher Education student portal/Safeer as soon as possible. You will not be able to access your Dental ID Card online until we have a U.S. mailing address on file. Once your U.S. Mailing address is updated within our system, your Dental ID Card will automatically be mailed to you at your U.S. address. Upon receipt of your Dental ID Card, please go to www.myuhc.com and register so that you can access your Dental benefits, locate a dentist, request a replacement or print a temporary Dental ID Card. You may also access this link within UHCSR My Account on the ID Card and Dental Plan pages. How to Find a Dental Health Care Provider Your plan includes in-network Dental administered through UHC Dental. You will need to select an In-Network Dental provider to ensure that your dental claims are paid with no cost to you. 1. Go to www.uhcsr.com/SACM 2. In the “Find Providers” section, select the Dental – My UHC Dental link 3. Select Location, Dentist Name or Practice Name to begin your search 4. Complete your search criteria and click Search 5. The Search results will indicate the provider’s address, phone number and other details 6. You may also print, email or export your search results You may also search for dental providers through your UHCSR My Account or at www.myuhc.com. Note: you will need your dental ID card to register at www.myuhc.com. How to reach UHC for Dental Information Our live Customer Service Representatives can be reached Monday through Friday from 7am-10pm Central Standard Time. Customer Service 1-877-881-8825 Website www.myuhc.com 17 Welcome to UHC Vision UnitedHealthcare has been trusted for more than 50 years to deliver affordable, innovative vision care solutions through experienced, customer-focused people and the nation’s most accessible, diversiﬁed vision care network. In-network, covered-in-full beneﬁts (up to the plan allowance and after applicable copay) include a comprehensive exam, eye glasses with standard single vision, lined bifocal, lined trifocal, or lenticular lenses, standard scratch-resistant coating* and the frame, or contact lenses in lieu of eyeglasses. Your vision plan includes: Benefit Frequency Comprehensive Exam(s) Spectacle Lenses Frames Contact Lenses in Lieu of Eyeglasses Once per calendar year Once per two calendar years Once per two calendar years Once per two calendar years In-Network Services Copays Exams $0 Materials $0 Vision Care Supplies 100% up to $200 maximum to be used towards the purchase of eye glass lenses, frames, and contact lenses every two calendar years. Discounts Laser Vision – UnitedHealthcare has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers. Members receive 15% oﬀ usual and customary pricing or 5% oﬀ promotional pricing at more than 550 network provider locations and even greater discounts through set pricing at LasikPlus locations. For more information, call 1-888-563-4497 or visit us at www.uhclasik.com. Additional Material – At a participating network provider you will receive up to a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insur- ance, and that UnitedHealthcare shall neither pay nor reimburse the provider or member for any funds owed or spent. Additional materials do not have to be purchased at the time of initial material purchase. Hearing Aids – As a UnitedHealthcare plan member, you can save on high-quality hearing aids when you buy them from hi HealthInnova- tions™. To find out more go to hiHealthInnovations.com. When placing your order use promo code myVision to get the special price discount. *On all orders processed through a company owned and contracted Lab network. 18 Account Information Log into www.myuhcvision.com to access your ID card, claims information and other helpful information. Did you know? When SACM members receive vision services from a network provider, the provider submits the claim and is paid directly by UHC. ID Card for Vision Benefits In order to take advantage of these vision benefits, simply show your medical ID card to your vision provider. No separate vision ID card is necessary. How to Find a Vision Care Provider Your plan includes in-network vision care administered through UHC. You will need to select an In-Network vision care provider to ensure that your vision claims are paid with no cost to you. 1. Go to www.myuhcvision.com 2. The provider link is on the left side of the page, at the bottom – You do not need to register to find a provider 3. Complete your search criteria and click Search 4. The Search results will indicate the provider’s address, phone number and other details How to reach UHC for Vision Information Our live Customer Service Representatives can be reached Monday through Friday from 7am-10pm Central Standard Time. Customer Service 1-866-808-8461 Website www.myuhcvision.com 19 Q1- What is the plan year for you policy (effective dates)? Q2- Is your plan an HMO, PPO, Traditional indemnity or other type of plan? How do you know this? Where did you find this information?- Q3- Define the term “co-pay.” Where does a co-pay apply within your coverage? How much does co-pay impact your decision to access healthcare? Q4- Define the term “deductible.” In dollars, what is the deductible in your policy? Q5- Define the term “co-insurance.” Where does co-insurance apply within your coverage? How does co-insurance differ from co-pay Q6- Are you required to identify a Primary Care Physician (PCP) when you enroll? Do you have a PCP? How did you choose your PCP? If you do not have a PCP– why not? Q7- Where does pre-certification or pre-authorization apply within your coverage? How does this requirement impact your decision to access healthcare? Q8- Describe the use of a formulary when a policy has pharmacy benefits. Does your coverage provide a forumlary? Q9- What, if any, wellness benefits are covered in your plan? Do you access them? Q10- What is meant when a policy has “out of network” stipulations. Does this impact your decision to access out of network healthcare?