Sandia Total Health administered by UnitedHealthcare - HBE

121 Pages·2014·0.7 MB·English

Sandia Total Health
administered by
UnitedHealthcare
(Employees, PreMedicare retirees, survivors,
long term disability terminees)
Revised: January 1, 2014

Program Summary
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Sandia National Laboratories is a multi-program laboratory managed and operated by Sandia Corporation, a wholly owned
subsidiary of Lockheed Martin Corporation, for the U.S. Department of Energy’s National Nuclear Security Administration under
contract DE-AC04-94AL85000. SAND Number: 2014-1714P
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Contents
Section 1. Introduction ................................................................................................. 1
Section 2. Summary of Changes ................................................................................. 3
Section 3. Accessing Care ........................................................................................... 5
In-Network and Out-of-Network Options ........................................................................ 5
Prior Authorization Requirements .................................................................................. 6
Medical Services.................................................................................................... 6
Behavioral Health .................................................................................................. 7
Predetermination of Benefits ......................................................................................... 9
Non-Emergency or Non-Urgent Care Away from Home ................................................ 9
Provider Networks ......................................................................................................... 9
UnitedHealth Premium® Designation Program ........................................................... 10
Provider Directories ..................................................................................................... 11
Provider Searches Online .................................................................................... 11
Employee Assistance Program .................................................................................... 12
Precertification Requirements for EAP Services ................................................. 12
NurseLine .................................................................................................................... 12
Telephone ............................................................................................................ 12
Informational Recorded Messages ...................................................................... 13
Live Nurse Chat ................................................................................................... 13
UnitedHealth Personal Health Support Program ......................................................... 13
Case Management Program ................................................................................ 13
Disease Management Program ........................................................................... 14
United Resource Networks (URN) Programs .............................................................. 15
Transplant Resource Services Program (Organ and Tissue Transplantation) .... 16
Cancer Resource Services Program ................................................................... 17
Congenital Heart Disease Resource Services Program ...................................... 17
Shared Savings Program............................................................................................. 17
HealthCare Fraud Information ..................................................................................... 18
Section 4. Deductibles, Out-of-Pocket Limits and Lifetime Limits ........................ 20
Deductibles .................................................................................................................. 20
Deductibles for Admissions Spanning Two Calendar Years ............................... 21
Coinsurance................................................................................................................. 22
Out-of-Pocket Limits .................................................................................................... 22
Lifetime Limits .............................................................................................................. 26
Section 5. Health Reimbursement Account ............................................................. 28
Health Reimbursement Account (HRA) Amounts ........................................................ 28
Events Resulting in Loss of HRA Funds .............................................................. 29
New Hires ............................................................................................................ 29
Eligible Mid-Year Election Change Events .......................................................... 30
Open Enrollment Changes for Dual Sandians ..................................................... 30
What Healthcare Expenses are Eligible for HRA Reimbursement .............................. 30
How the HRA Works .................................................................................................... 30
UHC Health Care Spending MasterCard ..................................................................... 32
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Claims Processing with an HCFSA and/or HRA .......................................................... 33
Medical Expenses................................................................................................ 34
Prescription Drugs ............................................................................................... 35
Setting up Direct Deposit ..................................................................................... 35
Turning off the Auto-Rollover Feature ......................................................................... 35
If you have an HRA.............................................................................................. 35
If you have both an HCFSA and HRA ................................................................. 35
Health Assessment and Biometric Screenings ............................................................ 36
Biometric Screenings Process ............................................................................. 36
Health Assessment Process ................................................................................ 37
Employees and their spouses/same gender domestic partners may complete a Health
Assessment by going to healthassessment.sandia.gov. Health assessments must be
completed by December 30 for funding for the following year, or by November 30th to
receive funding by the 1st January. ..................................................................... 37
Virgin Pulse Incentive Management Program ............................................................. 37
Tools and Resources to Become a More Informed Consumer .................................... 37
My UHC Website ................................................................................................. 37
Express Scripts Website ...................................................................................... 38
Section 6. Covered Medical Plan Services/Limitations ........................................... 40
Program Highlights ...................................................................................................... 40
Coverage Details ......................................................................................................... 41
Acupuncture Services .......................................................................................... 41
Auditory Integration Training ................................................................................ 41
Allergy Services ................................................................................................... 41
Ambulance Services ............................................................................................ 41
Behavioral Health Services .................................................................................. 42
Cancer Services .................................................................................................. 43
Chiropractic Services ........................................................................................... 44
Dental Services.................................................................................................... 44
Diabetes Services/Devices/Supplies ................................................................... 45
Diagnostic Tests .................................................................................................. 46
Durable Medical Equipment (DME) ..................................................................... 46
Emergency Care .................................................................................................. 48
Employee Assistance Program (EAP) ................................................................. 49
Eye Exam/Eyeglasses/Contact Lenses ............................................................... 49
Family Planning ................................................................................................... 49
Genetic Testing.................................................................................................... 50
Hearing Aids/Exam .............................................................................................. 50
Home Health Care Services ................................................................................ 50
Hospice Services ................................................................................................. 51
Infertility Services................................................................................................. 51
Injections in Physician’s Office ............................................................................ 52
Inpatient Care ...................................................................................................... 52
Maternity Services ............................................................................................... 53
Healthy Pregnancy Program................................................................... 54
Medical Supplies.................................................................................................. 54
Nutritional Counseling.......................................................................................... 55
Obesity Surgery ................................................................................................... 55
Office Visits .......................................................................................................... 55
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Organ Transplants ............................................................................................... 56
Outpatient Surgical Services ............................................................................... 56
Prescription Drugs (other than those dispensed by Express Scripts) .................. 57
Preventive Care ................................................................................................... 57
Well Baby Care (0-2 years) .................................................................... 58
Well Child Care (3-10 years) .................................................................. 59
Well Adolescent Care (11-18 years) ....................................................... 59
Well Adult Care (19 and older) ............................................................... 60
Immunizations / Vaccines ....................................................................... 61
Laboratory Services ................................................................................ 61
Cancer Screening Services .................................................................... 62
Pregnancy-Related Preventive Care Services ....................................... 63
Bone Density Testing (Osteoporosis screening) .................................... 63
Professional Fees for Surgical Procedures ......................................................... 63
Prosthetic Devices/Appliances ............................................................................ 64
Reconstructive Procedures .................................................................................. 65
Rehabilitation Services (Outpatient Therapies) ................................................... 65
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services ........................ 66
Temporomandibular Joint (TMJ) Syndrome ........................................................ 66
Urgent Care ......................................................................................................... 66
Section 7. Prescription Drug Program ...................................................................... 69
Eligibility ....................................................................................................................... 70
Covered Prescriptions ................................................................................................. 70
Covered Preventive Medications ......................................................................... 71
Preferred Versus Non-preferred Status ....................................................................... 72
Prescriptions Requiring Prior Authorization ................................................................. 74
Prescriptions Subject to Step Therapy Program .......................................................... 75
Prescriptions Subject to Quantity Limits ...................................................................... 75
Mail Service Program .................................................................................................. 76
Steps for Ordering and Receiving Mail Order Prescriptions (other than Specialty
Medications) ........................................................................................................ 76
Brand-To-Generic Substitution ............................................................................ 77
Retail Pharmacies........................................................................................................ 77
Using the Network Retail Pharmacies ................................................................. 78
Using the Out-of-Network Retail Pharmacies ...................................................... 78
Specialty Drug Management Program ......................................................................... 78
Steps for Ordering and Receiving Specialty Prescriptions .................................. 78
Section 8. What’s Not Covered – Exclusions ........................................................... 81
Section 9. Coordination of Benefits (COB) ............................................................... 89
Section 10. How to File a Claim ................................................................................... 91
Filing an Initial Claim .................................................................................................... 91
In-Network Claims Processing ............................................................................. 91
Out-of-Network Claims Processing ...................................................................... 91
Process for Out-of-Network Claims Processing for Medical Care .......... 92
Process for Out-of-Network Claims Processing for Prescription Drugs . 92
Benefits Payments ....................................................................................................... 92
Recovery of Excess Payment ...................................................................................... 93
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Section 11. How to File an Appeal............................................................................... 95
Filing an Appeal ........................................................................................................... 95
UnitedHealthcare Appeals Process ..................................................................... 96
Pre-Service and Post-Service Claim Appeals ........................................ 96
Urgent Claims Appeals ........................................................................... 97
Concurrent Care Claims .............................................................................................. 97
External Review Program ............................................................................................ 98
Standard External Review ................................................................................... 98
Expedited External Review ....................................................................................... 99
Express Scripts Appeals Process ...................................................................... 101
Pre-Service and Post-Service Claim: ................................................... 101
Urgent Claims (Expedited) Appeal: ...................................................... 101
Section 12. Sandia Total Health Administrative Services ....................................... 103
Claims Administrators ................................................................................................ 103
UHC Member Identification Cards ............................................................................. 103
Express Scripts Member Identification Cards ............................................................ 103
My UHC Website ....................................................................................................... 104
Express Scripts Website ............................................................................................ 104
Contact Telephone Numbers and Hours of Operation .............................................. 105
When You Change Your Address .............................................................................. 106
Section 13. Definitions ............................................................................................... 107
Section 14. UnitedHealth Allies Health Discount Program ..................................... 114

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Section 1. Introduction
This is a summary of highlights of the Sandia Total Health Program, a component of the Sandia Health
Benefits Plan for Employees (ERISA Plan 540) and the Sandia Health Benefits Plan for Retirees
(ERISA Plan 545). This Program summary is part of the Sandia Health Benefits Plan for Employees
Summary Plan Description or the Sandia Health Benefits Plan for Retirees Summary Plan Description.
It contains important information about your Sandia health benefits.
Certain capitalized words in this Program Summary have special meaning. These words have been
defined in the Definitions section of this Program Summary.
When the words “we”, “us”, and “our” are used in this document, we are referring to Sandia. When the
words “you” and “your” are used throughout this document, we are referring to people who are
Covered Members as defined in the Definitions section.
Many sections of this Program Summary are related to other sections of the Program Summary and to
information contained in the Sandia Health Benefits Plan for Employees Summary Plan Description or
the Sandia Health Benefits Plan for Retirees Summary Plan Description. You will not have all of the
information you need by reading only one section of one booklet.
Refer to the Sandia Health Benefits Plan for Employees Summary Plan Description or the Sandia
Health Benefits Plan for Retirees Summary Plan Description for information about eligibility,
enrollment, disenrollment, premiums, termination, coordination of benefits, subrogation and
reimbursement rights, when coverage ends, continuation of coverage provisions, and your rights under
the Employee Retirement Income Security Act of 1974 (ERISA).
To receive a paper copy of this Program Summary, other Program Summaries, the Sandia Health
Benefits Plan for Employees Summary Plan Description or the Sandia Health Benefits Plan for
Retirees Summary Plan Description, please contact Sandia HBE Customer Service at 505-844-HBES
(4237) or email [email protected]. These documents are also available electronically at
hbe.sandia.gov.
Since these documents will continue to be updated, we recommend that you check back on a regular
basis for the most recent version.

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Section 2. Summary of Changes

The following changes are effective January 1, 2014:

1. Per Healthcare Reform, Sandia Total Health Prescription Drug Program now offers
expanded coverage around Women’s Contraceptives, Vitamin D and Bowel
Preparation Agents. Please refer to Section 7 – Prescription Drug Program for more
information.

2. The Health Reimbursement Account (HRA) will now pay for the same expenses as the
Flexible Spending Account (FSA). As in 2013, FSA funds will be used prior to HRA
funds, since FSA funds do not carry over to the next year. You can use the money in
your HRA to pay eligible medical, prescription, dental, and vision expenses or any
other IRS 213 (d) eligible expenses.

3. HCFSA funds will now be paid directly to the provider for In-Network medical
expenses.

4. In order to receive HRA funding for each calendar year, heath assessments must be
completed by December 30 of the previous year, not December 31.

5. Reproductive Resource Services Program for Infertility is no longer offered.

6. In order to receive the preventive care benefit, the service must be submitted with a
preventive ICD-9 diagnostic code. If the service is submitted with a non-preventive
ICD-9 diagnostic code, it will be reimbursed up to the allowed non-preventive benefit
amount (depending on network), and you may be required to pay the difference.
It is solely up to the provider as to whether the service is coded as preventive or
diagnostic. Neither Sandia nor UHC can direct the provider to bill a service in any
particular way. The issue as to how it is billed is between you and your provider.

The following are clarifications / reminders for 2014:

1. PreMedicare retirees and their PreMedicare spouses, PreMedicare surviving spouses,
and PreMedicare Long term disability terminees are required to complete their health
assessment through your vendor website (UHC, BCBNM, or Kaiser) from October 1
through September 30th (of the current year) in order to receive funding in the
following year.

2. The Virgin HealthMiles Program is now called the Virgin Pulse Program.

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