Brokers' Frequently Asked Questions about the UniCare HMO Health Plan
The topics below contain a broad list of brokers' Frequently Asked Questions. Please use the links below to refine your search, or simply scroll down to locate the subjects of most relevance to you. The answers are only general descriptions of coverage. Please refer to certificates of coverage for more complete details about the plan including benefits, limitations and exclusions
About UniCare
Products
Pharmacy
Provider Network
Coverage/Benefits
Referrals
Enrollment and Renewals
Eligibility
Notification of Changes
HIPAA
Premiums/Rates and Quotes
Claims
Broker Eligibility/Commissions
NCQA
HEDIS
About UniCare
1. Who is UniCare?
UniCare is a national organization dedicated to the delivery of quality health care plans working together with its customers, brokers, providers and employers. Providing managed care and specialty health care services throughout the United States, UniCare is the national delivery system for WellPoint, Inc. (NYSE:WLP), one of the nation's largest publicly traded managed care companies serving the health care needs of more than 13 million members. There are several separate UniCare entities.
UniCare offers a comprehensive array of managed care health plans and specialty products that preserve member choice at competitive prices. UniCare currently serves 1.8 million medical members and currently employs over 3,400 associates with 38 locations in 13 states.
UniCare is committed to redefining the industry through a new generation of consumer friendly products that put individuals back in control of their health and financial future.
2. What is your mission statement?
Our mission and vision statement is as follows:
WellPoint Mission
The WellPoint Companies provide health security by offering a choice of quality branded health and
related financial services designed to meet changing expectations of individuals, families and their
sponsors throughout a lifelong relationship.
WellPoint Vision
WellPoint will redefine our industry through a new generation of consumer friendly products that
put individuals back in control of their health and financial future. The result will be:
- Significant increase in member satisfaction and enrollment;
- Superior returns to shareholders ;
- Excellent opportunities for associates;
- A highly respected national organization.
Click here to read recent news about WellPoint, our parent company.
3. What differentiates UniCare's services from other organizations?
While other companies offer the same old, pre-packaged benefits products - UniCare offers an alternative solution.
UniCare recognizes that what works for one company doesn't necessarily work for another.
That's why our full portfolio of health, pharmacy, dental, life and disability benefits products
may be tailored to meet the specific needs of your organization.
Our focus is on putting our clients and their associates back in control of their health care
and financial future. Through exceptional sales and account management staff who listen
to our clients, we can create benefits that evolve over time to meet the changing needs of
our clients and add the most value to you and your organization.
UniCare isn't just a solution for the moment - we're a trusted partner.
4. What do you view as UniCare's strengths?
In addition to our broad based product portfolio, patient focused care management, and service excellence, one of our core operational strengths is our Strategic Market Business Unit (MBU) approach. The MBU's concentrate on each unique customer segment and geography as a single entity with its own special needs. Through this unique customer-centered structure, innovative products and services are developed and delivered that meet the specific needs of each segment for choice, quality and cost efficiency. This approach serves as the foundation for all our activities and assures our products and services meet the diverse needs of your clients.
Products
5. What products and services do you offer?
UniCare understands that offering a variety of products is essential in developing a competitive associate benefits program. We offer an array of benefits products that address aspects of health care, prescription drug, dental, life and disability management, while satisfying the diverse needs of employers and associates. Our network management program is an evaluation program of managed care guidelines and performance outcome measures that monitor each network and network provider for quality and cost-efficiency. Our Healthcare Quality Assurance (HQA) program maximizes Plan Performance by managing the health care costs of the people who use it the most. UniCare's line of diverse products are designed to meet the needs of your organization. We pride ourselves on being an innovative organization that anticipates changing health care benefits dynamics and employer needs. We constantly strive to research, plan and develop new solutions that respond to employers' evolving objectives.
6. What is UniCare's approach to managing care for employees?
UniCare's managed care approach encompasses access, choice, quality and member empowerment. However, putting individuals back in control of their health plan goes beyond offering individuals access to a network. True managed care requires Care Management, an approach that recognizes that there are no "average" consumers of health care services. Less than 15% of the population is responsible for more than 70% of health care expenses. UniCare's integrated Care Management programs speak to the individual needs of each plan member. The result is an ability to control utilization with a member focused approach without sacrifice to cost savings.
7. Describe UniCare's disease management program.
UniCare recognizes that disease management helps members with chronic medical conditions maintain the best possible health status. Educational information is sent to certain members every few months. The information explains to members how the disease can affect their bodies and helps promote awareness of their chronic condition. Members also receive lists of available classes to help them learn more about their condition and take steps to manage it. Physicians receive listings of members who have these illnesses, copies of published literature, and devices to assist in managing members' conditions. UniCare strives to help members with chronic conditions live positive lifestyles.
Pharmacy
8. Does UniCare offer a managed pharmacy network?
WellPoint Pharmacy Management1, a UniCare affiliate, currently serves over 27 million members and provides pharmacy benefit administrative services to many UniCare plans. The network is national in scope and includes over 52,000 pharmacies, representing 85% of all pharmacies in the nation.
UniCare makes prescription plan costs easier to manage and control while enhancing employee satisfaction. Our prescription plans and our broad Pharmacy network offer all the key elements today's employer's demand in a prescription drug program.
Because the UniCare Prescription Drug Plan uses the WellPoint Pharmacy Management network, UniCare has the flexibility to develop programs that meet the diverse needs of your client. These strengths enable UniCare to develop innovative pharmacy management strategies that strive to maximize the quality of the pharmaceutical benefit in the most cost-effective manner.
1Professional Claim Services Inc. d.b.a. WellPoint Pharmacy Management
Provider Network
9. Describe your provider networks.
UniCare Health Plans of the Midwest, Inc.'s network serves 9 counties in the Chicago Metropolitan Area in Illinois and Northwest Indiana. The HMO network includes over 2,500 Primary Care Physicians and over 5,000 specialty care physicians. Complimenting the physician network UniCare HMO includes 93 hospitals and an extensive network of 600 ancillary health care institutions and professionals.
UniCare Health Plans of Texas, Inc.'s network covers 44 counties with over 1,300 Primary Care Physicians, 2,300 Specialists, 38 hospitals, and over 400 pharmacy locations. MethodistCare's provider network is comprised of a large physician group, Kelsey-Seybold Clinics, as well as several other individual physician associations such as: Baylor MedCare, Baylor-Methodist Primary Care Associates, Advanced IPA, Greater Houston Intercultural, Houston Metropolitan Health Network, Texas Children's Health Plan, University of Texas Galveston University Care Plus and other fine independent physicians throughout the greater Houston, Galveston, Beaumont and southeast Texas communities.
10. How often are your paper and online directories updated? (optional hotlink to provider directory)
Paper Directories are updated annually and online directories are updated monthly. Provider information is available online via our website, www.unicare.com. Through our online provider finder feature, members have the ability to print a listing of providers in their area. In addition, employees may also call Customer Service at anytime for questions regarding a physician's participation.
Coverage/Benefits
11. Will your plan send out detailed benefit information to employees?
New members will receive a "New Member packet" which will contain the UniCare HMO member certificate, Member Handbook and benefit summary.
12. What are pre-existing conditions and how do they impact coverage?
Neither UniCare Health Plans of the Midwest, Inc. nor UniCare Health Plans of Texas, Inc. have pre-existing restrictions.
13. Do you issue policies to minors?
UniCare's Large Group policies are issued to the employer not to individuals.
14. When does coverage begin?
Coverage begins once the member has satisfied the employer waiting period, if applicable.
15. What type of wellness or health promotion programs do you offer to your members?
The Preventive Health Services &Education department provides wellness information to UniCare Health Plans of the Midwest, Inc. members through worksite preventive health programs at the employer group site and in the community. The worksite preventive health services provide members with educational information on various health topics, seminars on preventive health issues, health risk assessments, learning centers targeting heart health, men's and women's health, complementary medicine, fitness, nutrition/weight management and stress management. To learn more about the Preventive Health Services &Education department members may call 1-877-217-8062 for information on the worksite and community services along with tobacco cessation. Healthy Living, a section of this website, is available to all members and includes a wealth of information through health articles and information on local and national health resources.
UniCare Health Plans of Texas, Inc. is evaluating existing programs for consideration in their growing market base.
Referrals
16. Does UniCare cover visits for specialty care?
Yes, UniCare Health Plans of the Midwest, Inc. and UniCare Health Plans of Texas, Inc. covers visits for specialty care. Because the member's primary care physician (PCP) is responsible for coordinating all health care, members should discuss their health care concerns and any medical treatment with their PCP. When specialty care is needed, the PCP will refer members to a specialist.
17. Does UniCare require that a member obtain a referral for OB/GYN services?
A female member may receive routine OB/GYN services from a woman's principal health care provider without a referral from her PCP. To do so, she must first designate the women's principal health care provider. Remember the woman's principal health care provider must have a referral relationship with the member's PCP. Members may confirm a referral relationship by accessing UniCare's Customer Service department, the provider directory or the provider listing on the website.
Enrollment and Renewals
18. What documentation is necessary for enrolling a group?
The following documentation is necessary for enrolling a group: application, binder check, must offer forms, new case installation paperwork and enrollment forms. Additional information may be required.
19. Does the renewal paperwork require signatures from the broker and/or the group, if there are no changes other than the renewal rates?
No, the renewal paperwork does not require signatures from the broker and/or group if there are no changes other than renewal rates.
20. What are the enrollment deadlines for a new group?
Enrollment deadlines are 15 days for key accounts with 51-250 employees, prior to the effective date and 21 days prior to effective date for major accounts with 251- 2000 employees.
21. How do I submit enrollment files to the plan?
You may submit enrollment files to the plan on paper or electronically (tape 750+ employees). After the case is initially enrolled we would accept online eligibility maintenance through myunicareonline.com.
22. When can I get the renewal for a company enrolled with your plan?
Renewals are typically provided 45 days prior to the renewal date. However, a request for early renewals may be accommodated depending on the size of the group.
Eligibility
23. What is the average turnaround time required to determine a group or a subscriber's eligibility or underwriting status?
The client determines if a member (subscriber) is eligible subject to UniCare approval. Typical processing time, once enrollment is received, is 3 business days. Please note processing time varies.
Notification of Changes
24. Who must be notified of a change of address or other administrative change?
The premium specialist or account manager should be notified by the benefits administrator of any administrative changes or changes to the company address.
25. How do I change the waiting /elimination/probationary period on a group's policy?
Request for change can be submitted to the account manager who will work with underwriting to determine if the change is approved and determine effective date of change.
26. What is the maximum waiting /elimination/probationary period a group can impose?
A waiting period pursuant to HIPAA is the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan.
HIPAA
27. What is HIPAA?
HIPAA, or Health Insurance Portability and Accountability Act is a federal health benefits law passed in 1996, effective July 1, 1997, which restricts pre-existing condition exclusion periods to ensure portability of health care coverage between plans, group and individual; require guaranteed issue and renewal of insurance coverage; prohibit plans from charging individuals higher premiums, copayments, and/or deductibles based on health status. The legislation also establishes a four-year medical savings account (MSA) demonstration project. The Act mandates standards for electronic data interchange (EDI) transactions and code sets, establishes uniform health care identifiers for providers, health plans, and employers. Compliance to HIPAA requires the use of ANSI ASC X12N (Version 4010) transaction standards and implementation guides. The final rules for transactions, code sets, privacy and security were published in the Federal Register on August 17, 2000. The compliance date of this rule is October 16, 2002. Compliance may be delayed one year. Under the terms of HIPAA, the rules and regulations apply to covered entities defined to include health plans, health care clearinghouses and health care providers, who transmit any health information in any electronic form in connection with transactions covered under HIPAA and who receive, maintain or disclose individually identifiable health information in any form. All covered entities must comply with the standards adopted by HIPAA by the applicable compliance dates. The modes of electronic transmission covered under HIPAA include the Internet, Extranet, leased lines, dial-up lines, private networks and those transmissions that are physically moved from one location to another using magnetic tape, disk, or compact disk media.
28. Who is eligible for HIPAA?
The provisions of HIPAA generally apply to group health plans and group health insurance issuers offering group health insurance coverage. This means that both the plan itself and the insurer (if any) are required to comply. HIPAA contains many exceptions, including exceptions for the following types of plan:
- Plans with fewer than 2 employees;
- Plans providing only certain incidental types of coverages, including accident, disability income, liability insurance, and workers compensation;
- Plans providing limited scope dental or vision benefits if provided under separate insurance policy or if coverage is elected by participants separately from the medical coverage;
- And health FSAs, if certain requirements are met.
29. How does crediting for preexisting condition waiting periods work under HIPAA?
Many plans use the "standard method" to credit coverage.
The individual receives credit for previous coverage that occurred without
a break in coverage of 63 days or more. Coverage prior to a 63 day break
or more is not credited against a preexisting condition exclusion period.
A plan or issuer may elect the "alternative method" for crediting
coverage for all employees. The plan or issuer determines the amount
of an individual's creditable coverage for any of the five specified
categories of benefits which are mental health, substance abuse treatment,
prescription drugs, dental care and vision care. The standard method
is used to determine an individual's creditable coverage for benefits
other than the five categories that a plan or issuer may use. (The plan
or issuer may use some or all of these categories.)
With the alternative method, the plan or issuer looks to see is an individual has coverage within a category of benefits (regardless of the specific level of benefits provided within that category).
If your employer's plan requests information from your prior plan regarding any of the categories of benefits under the alternative method, your former plan must provide such information.
30. How will the latest HIPAA requirements regarding security, privacy, etc. affect the products your plan offers?
The requirements do not affect the products offered, however, they do affect the way UniCare does business. UniCare's practices and procedures are in compliance with HIPAA requirements.
31. What qualifies as creditable coverage?
Most health coverage is creditable coverage, such as coverage under a group health plan (including COBRA continuation coverage), HMO, individual health insurance policy, Medicaid or Medicare.
Coverage consisting solely of "excepted benefits," such as coverage solely for limited-scope dental or vision benefits is not included as creditable coverage.
Days in a waiting period during which you have no other coverage are not creditable coverage under the plan, nor are these days taken into account when determining a significant break in coverage (generally a break of 63 days or more). This 63-day break period may be extended under state law if your coverage is insured through an insurance company or offered through an HMO.
32. How does an employer-imposed waiting period affect a break in coverage?
A period of creditable coverage shall not be counted if it is before a significant break in coverage if, after such period and before the enrollment date, there was a 63 day period during all of which the individual was not covered under any creditable coverage. A waiting period is not treated as a break in coverage. Any period that an individual is in a waiting period for any coverage under a group health plan (or for group health insurance coverage) or is in an affiliation period shall not be taken into account in determining the continuous period.
33. How does a new employer or insurance carrier know that an employee had prior group coverage?
Group health plans and health insurance issuers are required to provide a certificate of coverage to an individual for documentation of prior creditable coverage. A certificate of creditable coverage shall be provided automatically by the plan or issuer when an individual either loses coverage under the plan or becomes entitled to elect COBRA continuation coverage and when an individual's COBRA continuation coverage ceases and shall also be provided, if requested, before the individual loses coverage or within 24 months of losing coverage.
34. How does HIPAA legislation affect individual coverage?
In general when leaving group coverage eligible individuals with prior group coverage can receive guaranteed individual coverage. Each state may implement statutes and regulations to modify the requirements but the modifications must be at least as favorable as the requirements pursuant to HIPAA.
HIPAA portability, special enrollment and nondiscrimination rules generally apply to group health plan and health insurance issuers offering group health insurance coverage. In contrast, individual polices of health insurance are subject to HIPAA' s individual insurance market rules, which include guaranteed availability, guaranteed renewability and certificate of creditable coverage requirements.
Group to individual conversion coverage, is considered individual health insurance coverage. Consequently, the individual market rules generally will apply to such conversion coverage. However, an insurer that offers conversion coverage to former group plan participants but does not otherwise offer coverage in the individual market will not, for the purposes of guaranteed-availability requirement, be considered to be and an insurer offering coverage in the individual market.
Premiums/Rates and Quotes
35. Is payment required at the time of application?
Yes, the first month's premium is required prior to case set up.
36. How do I obtain a small group quote? (less than 50 employees)
For a small group quote, please call 1(800)UniCare.
37. How do I obtain a large group quote?
To obtain a large group quote, you would submit an RFP or RFI or census information to the assigned Sales Representative or Vice President of Sales and Marketing. Call 1(800)UniCare or Select Your State to see what plans are available in your region.
38. What percentage of premium does the employer have to contribute?
The employer would typically contribute 75% of the premium for single coverage and 0% for family coverage.
Claims
39. How are claims handled for employees with more than one health insurance plan?
Health benefits are coordinated with any other health insurance plan in effect at the time services are rendered, to ensure the total benefits paid by UniCare and any other group health plan do not exceed 100% of the allowable expenses.
The member's enrollment form asks for information about any other group coverage for which the member or any other family members may be eligible. Claims analysts use this information to coordinate benefits between other insurance carriers and UniCare. It is also used to identify the carrier that has the primary responsibility for covering medical services.
Broker Eligibility/Commissions
40. How do I become a broker for your company?
Please contact Sarah Tatum-Bourbeau at 1(800) 922-7302 for details.
41. How and when will I receive commission payments?
You [the broker] will receive payment usually by the second week of each month after the receipt of the premium. You can receive either a "live" check or can request the commissions to be deposited into your bank account.
42. Can I have my commission deposited directly to my bank account?
Yes. You [the broker] would need to fill out the Electronic Funds Transfer Request form. Once the form is completed, you would need to send the form along with a copy of a blank deposit slip for the account receiving the direct deposit. Please note: only checking accounts can be accepted for direct deposit. If you have further questions, please call 1(800) 922-7302.
NCQA
43. Is UniCare NCQA accredited?
UniCare Health Plans of the Midwest, Inc. has been granted a full three-year Excellent Accreditation by the National Committee for Quality Assurance, it's highest rating. This achievement demonstrates UniCare's commitment to providing quality health care benefits and services to employers and to members. NCQA accreditation is a voluntary process. The surveys include rigorous on-site and off-site evaluations of over 60 standards and selected HEDIS® performance measures. A team of physicians and managed care experts conducts the accreditation surveys. A national oversight committee of physicians analyzes the team's findings and assigns an accreditation level based on the performance level of each plan being evaluated to NCQA's standards.
HEDIS
44. Does UniCare participate in HEDIS data collection?
UniCare Health Plans of the Midwest, Inc. has participated in HEDIS data collection and reporting for its HMO plan for a number of years. The Plan recognizes HEDIS as an important tool for the managed care industry as it addresses a full spectrum of health care issues from prevention and early detection to acute and chronic care. HEDIS also serves as a helpful tool for employers and members when accessing the competency level of a managed care plan. The HEDIS program is sponsored and maintained by NCQA, an independent non-profit organization that measures and evaluates the effectiveness of managed care. HEDIS was developed by a committee of health care consumers, providers, public health officials and others. HEDIS measures a plan's performance in several key areas, including effectiveness of care, stability of the health plan, accessibility/availability of care, membership and satisfaction, and use of services.
