d) Área de Influencia
ESTUDIOS REQUERIDOS
As an UnitedHealthcare® MedicareDirectSM enrollee, you will be financially responsible for the monthly Health Plan Premium (if applicable), as well as Copayments and Coinsurance amounts that are listed in the Retiree Benefits Summary and Insert. You must also continue to pay your Medicare Part A, if applicable and Part B Premiums, if applicable.
UnitedHealthcare® MedicareDirectSMHealth Plan Premium – Generally, your Plan Sponsor, State Health Benefit Plan, is responsible for making payment of any applicable monthly Health Plan Premium directly to us on behalf of its UnitedHealthcare MedicareDirect Retiree Plan Enrollees and their eligible dependent(s). Your Plan Sponsor, State Health Benefit Plan, determines the amount of any retiree subscriber contribution toward Health Plan Premiums. Some Plan Sponsors, however, have made arrangements with us to bill you, the Enrollee, directly for Health Plan Premiums. If this is the case, your monthly Health Plan Premium is due on the first of each month for that month’s coverage.
• Medicare Part A Premium – If applicable, M/most Medicare beneficiaries are automatically entitled to Medicare Hospital Insurance (Part A). If you are not entitled to Medicare Part A, and you have purchased Part A through Social Security, you must continue to pay your Medicare
Part A Premium.
• Medicare Part B Premium – If applicable, a monthly premium paid to Medicare to cover Supplemental Medical Insurance (Part B). As an UnitedHealthcare® MedicareDirectSMEnrollee, you must continue to pay your Medicare Part B Premium. If you receive a Social Security annuity check, this premium is usually automatically deducted from your check. Otherwise, the premium is paid directly to Medicare by you or someone on your behalf such as Medicaid.
• Medicare Part D Premium – If applicable, A/a monthly premium paid to Medicare Part D providers, like us, to cover Part D prescription drug coverage (if you are responsible for paying your Health Plan Premium directly to us). Not all UnitedHealthcare® MedicareDirectSM benefit plans that offer Medicare Part D prescription drug coverage have a Medicare Part D Premium.
What Happens if You Don’t Pay Your Health Plan Premiums?
If your Plan Sponsor, State Health Benefit Plan, does not pay your Health Plan Premium for the
UnitedHealthcare® MedicareDirectSMRetiree Plan, then we may disenroll you from the group plan. Please contact your Plan Sponsor regarding your options and the impact of being disenrolled.
If you are responsible for paying your Health Plan Premium directly to us, we have the right to Disenroll you from UnitedHealthcare® MedicareDirectSM for failure to pay Health Plan Premiums. However, prior to such action, we will:
(a) attempt to contact you by letter within twenty (20) days after the date of the delinquent charges are due, (b) advise you in the letter that your failure to pay Health Plan Premiums within a thirty (30) day grace period
may result in your Disenrollment, and
(c) include an explanation of your rights under the Grievance procedures.
Should you decide later to re-enroll in UnitedHealthcare® MedicareDirectSMor to enroll in another plan we offer, you may be required to pay any outstanding Health Plan Premiums due from your previous enrollment in UnitedHealthcare® MedicareDirectSM.
Until you are notified of your Disenrollment, you will continue to be an UnitedHealthcare®
MedicareDirectSM Enrollee. For details on Disenrollment for non-payment of Health Plan Premiums, see Section 9.
Changes in Health Plan Premiums
Rate changes and employer-sponsored benefit changes for UnitedHealthcare® MedicareDirectSM Retiree Plan Enrollees are subject to contractual arrangements between your Plan Sponsor, State Health Benefit Plan, and us. Your Plan Sponsor, State Health Benefit Plan, is responsible for notifying you of any UnitedHealthcare®
MedicareDirectSM Retiree Plan premium changes, contribution changes or employer-sponsored benefit changes, thirty (30) days before they become effective.
Changes in the level of health care coverage may occur at the beginning of each Calendar Year and/or retiree group contract year. You will receive a written notice at least thirty (30) days prior to the date when such change shall become effective.
Enrollees in some states may be eligible for certain Medigap protections if their UnitedHealthcare®
MedicareDirectSM Retiree Plan has a reduction in benefits or increases in Health Plan Premiums, Copayments or Coinsurance. For State specific information, please call Customer Service, your State’s Department of Insurance or your local State Health Insurance Program (SHIP). Please refer to the SHIP Table in Section 2 for address and phone number information.
What extra help is available to help pay my plan costs?
Medicare provides “extra help” to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you will get help paying for any Medicare drug plan’s monthly premium (if applicable), yearly deductible (if applicable), and prescription copayments. If you qualify, this extra help will count toward your out-of-pocket costs.
Out-of-Pocket Maximum
If applicable to your benefit plan, this is the maximum amount that you could pay for Covered Services incurred each Calendar Year. Your Out-of-Pocket Maximum includes those Copayments and/or Coinsurance amounts that are listed in the Retiree Benefits Summary and Insert. Some Covered Services do not count towards your Out-of-Pocket Maximum and these are listed in the Retiree Benefits Summary and Insert also.
Expenses not covered by UnitedHealthcare® MedicareDirectSMRetiree Plan do NOT count toward your annual Out-of-Pocket Maximum. Once you have reached your Out-of-Pocket Maximum you are no longer required to pay any Copayments or Coinsurance amounts for Covered Services. Enrollees must retain receipts for
Copayments that apply to the annual Out-of-Pocket Maximum and submit them to us, once the annual Out-of- Pocket Maximum has been reached.
Reaching the Out-of-Pocket Maximum
Our claims processing system automatically tracks the amounts you pay for Claims submitted by Providers. You will receive an Explanation of Benefits for each Claim we receive for services that were provided to you. Each Explanation of Benefits shows the amount of cost-sharing that has been applied to your Out-of-Pocket Maximum. You can also call Customer Service to request your Out-of-Pocket Maximum information. When you meet your Out-of-Pocket Maximum, the system will no longer apply a Copayment or Coinsurance amount, unless the service you received does not apply to the Out-of-Pocket Maximum. However, if you think you have reached the annual Out-of-Pocket Maximum and we are still applying cost-sharing, please notify us in
writing that excess Copayments and Coinsurance have been paid no later than 90 days after the end of the Calendar Year in which the Copayments or Coinsurance were incurred. We will reimburse you. This
information must include proof satisfactory to us of the payment of Copayments or Coinsurance. Please send to:
Customer Service P.O. Box 30883
Salt Lake City, UT 84130-0883
If you Disenroll from UnitedHealthcare® MedicareDirectSM and then seek reinstatement under the plan before the end of the Calendar Year in which you Disenrolled, any amount that you accumulated toward your Out-of- Pocket Maximum before you Disenrolled continues to apply toward your Out-of-Pocket Maximum for that Calendar Year.