Important Things to Know

Underwriting

The Group underwriting guidelines have been developed in an effort to offer coverage to all eligible Group businesses and their employees. UniCare Group Underwriting uses a point system to evaluate each group. Criteria used in the evaluation process include employer contribution, employee participation, group size, the number of COBRA eligible employees, the group’s health status, and the group’s tobacco usage. If a group is offered a particular rate level, then all of the group’s employees will be offered the coverage at the same rate level.

Employer Contribution

MEDICAL:
Employers must contribute either: a minimum of 50% of the employee’s monthly health premium (Traditional Contribution); $100 per employee per month or the employee’s actual premium for the month (whichever is less) for the employee’s health premium (Defined Contribution 100); $80 per employee per month or the employee’s actual premium for the month (whichever is less) for the employee’s health premium (Defined Contribution 80); or any fixed dollar amount greater than $100 per employee per month or the employees’ actual premium for the month (whichever is less) for the employee’s health premium (Defined Contribution Select). The employer is not required to contribute toward dependent’s coverage.

DENTAL:
Employers must contribute either: a minimum of 50% of the employee’s monthly dental premium (Traditional Contribution); $15 per employee per month or the employee’s actual premium for the month (whichever is less) for the employee’s dental premium (Defined Contribution 15); or any fixed dollar amount greater than $15 per employee per month for the employee’s dental premium or the employee’s actual premium for the month (whichever is less) for employee’s dental premium (Dental Contribution Select). The employer is not required to contribute towards dependent’s coverage.

LIFE:
Employers must contribute a minimum of 50% of the employee’s life premiums. The employer is not required to contribute towards the cost of dependent’s coverage.

EMPLOYEE PARTICIPATION: The standard employer’s participation requirement in the group’s health plan is a minimum of 75% of eligible employees. If the employer is paying 100 percent of the employee’s premium, then all eligible employees must enroll. If the employer pays less than 100 percent of the employee’s premium, at least 75 percent of eligible employees must enroll.

Employees/dependents who decline coverage because they are covered by another group medical plan may be considered ineligible.

If an employee or a dependent declines coverage, he or she must complete the section on "Employee Information" and "Coverage Declination," of the employee application. The application must then be sent to UniCare.

Changes in Premium Rates

Premiums for a specific employer may be adjusted based on various factors including, but not limited to, claims experience, health, the group’s duration with UniCare, as well as general Group pool rate changes.

Renewability

The group policy and coverage for all insured persons shall terminate for the following reasons including, but not limited to:

• failure to provide required information or documentation,
• fraud or material misrepresentations,
• nonpayment of premium, or,
• failure to meet minimum contribution and participation requirements
• failure to maintain status as a group
• UniCare cancels all groups with your plan or all small employer group health benefit plans in the state

Coverage for an insured employee and insured dependent will end for the following reasons including, but not limited to:

• when an insured employer/insured dependent no longer meets the definition of an eligible employee/eligible dependent
• nonpayment of premium
• the group policy terminates
• the lifetime maximum benefit of the plan is exhausted
• fraud or material misrepresentation
• for an insured dependent when the insured employer’s coverage terminates unless due to exhaustion of the lifetime maximum benefits

COBRA/FMLA eligible groups

Employers qualified for coverage under either COBRA (Consolidated Omnibus Budget Reconciliation Act) or FMLA (Family and Medical Leave Act) must complete the questionnaire, including the qualifying event and date continuation coverage began for each applicable employee.

Medicare

Based on federal law, if your business employs less than 20 employees in a year, if any of your employees becomes 65 years of age and maintains employment eligibility, his or her primary health carrier must be Medicare. If your business employs 20 or more employees in a year, UniCare will remain the primary carrier if elected by the employee.

Valid enrollment

False or missing information or lack of any required enrollment material may form the basis for voiding coverage from the date of issue. No benefits will be paid for any claim submitted, and premiums already paid for the time period for which coverage is rescinded will be refunded, less claims paid.

Out-of-state employees

A maximum of 10 percent of the enrolling employees may reside outside of Indiana.

Utilization review, preservice review, and authorization program

Sometimes a medical condition may require hospitalization for treatment. With so many treatments available, it’s important to be sure you really need to be in the hospital and your stay is only as long as the condition requires.

UniCare’s preservice reviews are designed to determine the medical necessity of a hospitalization, so that unnecessary costs and procedures are avoided. A preservice review is required for all hospitalizations and for services received from an ambulatory surgical center. These reviews are vital to using the plan properly because UniCare will cover services only if we determine them to be medically necessary.

The authorization program works in a similar fashion. It requires review of certain services to assist our members in receiving the maximum allowable benefit while avoiding unnecessary costs. These services include, for example, organ or tissue transplants, home health services, skilled nursing facility services, hospice services, and infusion therapy services.

Preservice reviews and/or authorizations must be received prior to services being rendered.

Third Party Liability

If a member is injured, the responsible party may be legally obligated to pay for medical expenses related to that injury. UniCare may recover benefits it has paid for those medical expenses, up to the amount paid by UniCare.