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Evidence of Coverage andDisclosure FormEffective January 1, 2020UnitedHealthcare Group Medicare Advantagewith Dental and VisionPreferred Provider Organization (PPO)Contracted by the CalPERS Board of Administration Under thePublic Employees’ Medical & Hospital Care Act (PEMHCA)Y0066 EOC H2001 816 000 2020 C UHEX20PP4484700 001
January 1, 2020 – December 31, 2020Evidence of CoverageYour Medicare Health Benefits and Services and PrescriptionDrug Coverage as a Member of our plan.This booklet gives you the details about your Medicare health care and prescription drugcoverage January 1, 2020 – December 31, 2020. It explains how to get coverage for the healthcare services and prescription drugs you need.This is an important legal document. Please keep it in a safe place.This plan, UnitedHealthcare Group Medicare Advantage (PPO), is insured throughUnitedHealthcare Insurance Company or one of its affiliates. (When this Evidence of Coveragesays “we,” “us,” or “our,” it means UnitedHealthcare. When it says “plan” or “our plan,” it meansUnitedHealthcare Group Medicare Advantage (PPO).This document may be available in an alternate format such as Braille, large print or audio.Please contact our Customer Service number at 1-888-867-5581, TTY: 711, 7 a.m. - 8 p.m. localtime, 7 days a week, for additional information.Benefits, premium, and/or copayments/coinsurance may change on January 1, 2021.The formulary, pharmacy network, and provider network may change at any time. You will receivenotice when necessary.This Evidence of Coverage is subject to change based on new or revised requirements from theCenters for Medicare & Medicaid Services (CMS).Y0066 EOC H2001 816 000 2020 C OMB Approval 0938-1051 (Expires: December 31, 2021)
2020 Evidence of Coverage for UnitedHealthcare Group Medicare Advantage (PPO)Table of Contents2020 Evidence of CoverageTable of ContentsThis list of chapters and page numbers is your starting point. For more help in finding informationyou need, go to the first page of a chapter. You will find a detailed list of topics at the beginning ofeach chapter.Chapter 1Getting started as a member.1-1Explains what it means to be in a Medicare health plan and how to use this booklet.Tells about materials we will send you, your plan premium, the Part D late enrollmentpenalty, your UnitedHealthcare member ID card, and keeping your membershiprecord up to date.Chapter 2Important phone numbers and resources.2-1Tells you how to get in touch with our plan (UnitedHealthcare Group MedicareAdvantage (PPO)) and with other organizations including Medicare, the State HealthInsurance Assistance Program (SHIP), the Quality Improvement Organization,Social Security, Medicaid (the state health insurance program for people with lowincomes), programs that help people pay for their prescription drugs, and theRailroad Retirement Board.Chapter 3Using the plan’s coverage for your medical services.3-1Explains important things you need to know about getting your medical care as amember of our plan. Topics include using the providers in the plan’s network andhow to get care when you have an emergency.Chapter 4Medical Benefits Chart (what is covered and what you pay).4-1Gives the details about which types of medical care are covered and not covered foryou as a member of our plan. Explains how much you will pay as your share of thecost for your covered medical care.Chapter 5Using the plan’s coverage for your Part D prescription drugs.5-1Explains rules you need to follow when you get your Part D drugs. Tells how to usethe plan’s List of Covered Drugs (Formulary) to find out which drugs are covered.Tells which kinds of drugs are not covered. Explains several kinds of restrictions thatapply to coverage for certain drugs. Explains where to get your prescriptions filled.Tells about the plan’s programs for drug safety and managing medications.
2020 Evidence of Coverage for UnitedHealthcare Group Medicare Advantage (PPO)Table of ContentsChapter 6What you pay for your Part D prescription drugs.6-1Tells about the 4 stages of drug coverage (Deductible Stage, Initial CoverageStage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stagesaffect what you pay for your drugs. Explains the 4 cost-sharing tiers for your Part Ddrugs and tells what you must pay for a drug in each cost-sharing tier.Chapter 7 sking us to pay our share of a bill you have received for covered medicalAservices or drugs.7-1Explains when and how to send a bill to us when you want to ask us to pay you backfor our share of the cost for your covered services or drugs.Chapter 8Your rights and responsibilities.8-1Explains the rights and responsibilities you have as a member of our plan. Tells whatyou can do if you think your rights are not being respected.Chapter 9 hat to do if you have a problem or complaint (coverage decisions,Wappeals, complaints).9-1Tells you step-by-step what to do if you are having problems or concerns as amember of our plan. Explains how to ask for coverage decisions and make appeals if you are havingtrouble getting the medical care or prescription drugs you think are coveredby our plan. This includes asking us to make exceptions to the rules or extrarestrictions on your coverage for prescription drugs, and asking us to keepcovering hospital care and certain types of medical services if you think yourcoverage is ending too soon. Explains how to make complaints about quality of care, waiting times, customerservice, and other concerns.Chapter 10Ending your membership in the plan.10-1Explains when and how you can end your membership in the plan. Explainssituations in which our plan is required to end your membership.Chapter 11Legal notices.11-1Includes notices about governing law and about nondiscrimination.Chapter 12Definitions of important words.12-1Explains key terms used in this booklet.
CHAPTER 1Getting started as a member
2020 Evidence of Coverage for UnitedHealthcare Group Medicare Advantage (PPO)Chapter 1: Getting started as a member1-1Chapter 1Getting started as a memberSECTION 1Introduction.1-3Section 1.1 You are enrolled in UnitedHealthcare Group MedicareAdvantage (PPO), which is a Medicare PPO Plan 1-3Section 1.2 What is the Evidence of Coverage booklet about?. 1-3Section 1.3 Legal information about the Evidence of Coverage. 1-3SECTION 2What makes you eligible to be a plan member?.1-4Section 2.1 Your eligibility requirements. 1-4Section 2.2 What are Medicare Part A and Medicare Part B?. 1-4Section 2.3 Here is the plan service area for UnitedHealthcare GroupMedicare Advantage (PPO) 1-5Section 2.4 U.S. Citizen or Lawful Presence. 1-5SECTION 3What other materials will you get from us?.1-5Section 3.1 Your UnitedHealthcare member ID card — Use it to get allcovered care and prescription drugs 1-5Section 3.2 The Provider Directory: Your guide to all providers in theplan’s network 1-6Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network.1-6Section 3.4 The plan’s List of Covered Drugs (Formulary). 1-7Section 3.5 The Part D Explanation of Benefits (the “Part D EOB”):Reports with a summary of payments made for your Part Dprescription drugs 1-7SECTION 4 Your monthly premium for the plan 1-8Section 4.1 How much is your plan premium?. 1-8SECTION 5Do you have to pay the Part D “late enrollment penalty”?.1-8Section 5.1 What is the Part D “late enrollment penalty”?. 1-8Section 5.2 How much is the Part D late enrollment penalty?. 1-9Section 5.3 In some situations, you can enroll late and not have to pay thepenalty 1-9Section 5.4 What can you do if you disagree about your Part D late enrollmentpenalty? 1-10
2020 Evidence of Coverage for UnitedHealthcare Group Medicare Advantage (PPO)Chapter 1: Getting started as a memberSECTION 61-2Do you have to pay an extra Part D amount because of your income?.1-10Section 6.1 Who pays an extra Part D amount because of income?.1-10Section 6.2 How much is the extra Part D amount?.1-11Section 6.3 What can you do if you disagree about paying an extra Part Damount? 1-11Section 6.4 What happens if you do not pay the extra Part D amount?.1-11SECTION 7More information about your monthly premium.1-11Section 7.1 There are several ways you can pay your plan premium.1-11Section 7.2 Can we change your monthly plan premium during the year?.1-12SECTION 8Please keep your plan membership record up to date.1-12Section 8.1 How to help make sure that we have accurate informationabout you 1-12SECTION 9We protect the privacy of your personal health information.1-13Section 9.1 We make sure that your health information is protected.1-13SECTION 10 How other insurance works with our plan.1-13Section 10.1 Which plan pays first when you have other insurance?.1-13
2020 Evidence of Coverage for UnitedHealthcare Group Medicare Advantage (PPO)Chapter 1: Getting started as a memberSECTION 1Section 1.11-3IntroductionYou are enrolled in UnitedHealthcare Group Medicare Advantage (PPO),which is a Medicare PPO PlanYou are covered by Medicare, and you have chosen to get your Medicare health care and yourprescription drug coverage through our plan, UnitedHealthcare Group Medicare Advantage (PPO).There are different types of Medicare health plans. Our plan is a Medicare Advantage PPO Plan(PPO stands for Preferred Provider Organization). Like all Medicare health plans, this Medicare PPOis approved by Medicare and run by a private company.Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the PatientProtection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visitthe Internal Revenue Service (IRS) website at: sand-Families for more information.Section 1.2What is the Evidence of Coverage booklet about?This Evidence of Coverage booklet tells you how to get your Medicare medical care andprescription drugs covered through our plan. This booklet explains your rights and responsibilities,what is covered, and what you pay as a member of the plan.When the Agreement is purchased by the Group to provide benefits under a welfare plan governedby the Employee Retirement Income Security Act (ERISA), 29 U.S.C. §1001 et seq., we are not theplan administrator or named fiduciary of the welfare plan, as those terms are used in ERISA.The words “coverage” and “covered services” refer to the medical care, services and prescriptiondrugs available to you as a member of the plan.It’s important for you to learn what the plan’s rules are and what services are available to you. Weencourage you to set aside some time to look through this Evidence of Coverage booklet. If youare confused or concerned or just have a question, please contact our plan’s Customer Service(phone numbers are printed on the back cover of this booklet).Section 1.3Legal information about the Evidence of CoverageIt’s part of our contract with youThis Evidence of Coverage is part of our contract with you about how the plan covers your care.Other parts of this contract include your enrollment form, or your verbal or electronic election of ourplan, the List of Covered Drugs (Formulary), and any notices you receive from us about changesto your coverage or conditions that affect your coverage. These notices are sometimes called“riders” or “amendments.”The contract is in effect for months in which you are enrolled in the plan between January 1, 2020,and December 31, 2020.
2020 Evidence of Coverage for UnitedHealthcare Group Medicare Advantage (PPO)Chapter 1: Getting started as a member1-4Each plan year, Medicare allows us to make changes to the plans that we offer. This means we canchange the costs and benefits of the plan after December 31, 2020. We can also choose to stopoffering the plan, or to offer it in a different service area, after December 31, 2020.Medicare must approve our plan each yearMedicare (the Centers for Medicare & Medicaid Services) must approve our plan each year. Youcan continue to get Medicare coverage as a member of our plan as long as we choose to continueto offer the plan and Medicare renews its approval of the plan.SECTION 2Section 2.1What makes you eligible to be a plan member?Your eligibility requirementsYou are eligible for membership in our plan as long as: You meet the eligibility requirements of your former employer or union group (plan sponsor) You have both Medicare Part A and Medicare Part B (Section 2.2 tells you about MedicarePart A and Medicare Part B) — and — you live in our geographic service area (Section 2.3 below describes our service area) — and — you are a United States citizen or are lawfully present in the United States — and — you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such asif you develop ESRD when you are already a member of a plan that we offer, or you were amember of a different plan that was terminated, or in some cases if you are enrolling in a formeremployer or union group sponsored plan.Section 2.2What are Medicare Part A and Medicare Part B?When you first signed up for Medicare, you received information about what services are coveredunder Medicare Part A and Medicare Part B. Remember: Medicare Part A generally helps cover services provided by hospitals (for inpatient services),skilled nursing facilities, or home health agencies. Medicare Part B is for most other medical services (such as physician’s services and otheroutpatient services) and certain items (such as durable medical equipment (DME) andsupplies).If you are not entitled to Medicare Part A, please refer to your plan sponsor’s enrollment materials,or contact your plan sponsor directly to determine if you are eligible to enroll in our plan. Some plansponsors have made arrangements with us to offer a Medicare Advantage plan even if though youaren’t entitled to Part A based on your former employment.
2020 Evidence of Coverage for UnitedHealthcare Group Medicare Advantage (PPO)Chapter 1: Getting started as a memberSection 2.31-5Here is the plan service area for UnitedHealthcare Group MedicareAdvantage (PPO)Our plan is available only to individuals who live in our plan service area. To remain a member ofour plan, you must continue to reside in the plan service area. The service area is described below.Our service area includes the 50 United States, the District of Columbia and all U.S. territories.If you plan to move out of the service area, please contact Customer Service (phone numbers areprinted on the back cover of this booklet) and your plan sponsor.It is also important that you call Social Security if you move or change your mailing address. Youcan find phone numbers and contact information for Social Security in Chapter 2, Section 5.Section 2.4U.S. Citizen or Lawful PresenceA member of a Medicare health plan must be a U.S. citizen or lawfully present in the UnitedStates. Medicare (the Centers for Medicare & Medicaid Services) will notify UnitedHealthcare Group Medicare Advantage (PPO) if you are not eligible to remain a member on this basis.UnitedHealthcare Group Medicare Advantage (PPO) must disenroll you if you do not meet thisrequirement.SECTION 3Section 3.1What other materials will you get from us?Your UnitedHealthcare member ID card — Use it to get all covered careand prescription drugsWhile you are a member of our plan, you must use your UnitedHealthcare member ID card forour plan whenever you get any services covered by this plan and for prescription drugs you get atnetwork pharmacies. You should also show the provider your Medicaid card, if applicable. Here’s asample UnitedHealthcare member ID card to show you what yours will look like:Customer Service Hours: Monday – Friday 7:00 a.m. to 8:00 p.m. HSTHealth Plan (80840): 911-87726-04Member ID: 999999999-99Member:SUBSCRIBER BROWNWNCopay:: PCP/ Spec/ ER 10/ 45/ 65H0000 PBP# 000Groupp NumNumber:1010110PayePayerr ID:9999999999RxBin:610097RxPCN:9999RxGrp:COSFor MembersWebsite:Customer Service:NurseLine:Behavioral -99 9 TTY 7117111-999-999-9999999-999-9999 TTY 771111-999-999-999999-999-9999 TTTTY 7111For unitedh1-999-999-9999Medical Claim Address:Addres PP.O.O Box 30995 Salt Lake City, UT 84130-0995UHCReferralRequiredPharmacy Claims OptumRx P.O. Box 29045, Hot Springs, AR 71903For Pharmacists 1-999-999-9999
2020 Evidence of Coverage for UnitedHealthcare Group Medicare Advantage (PPO)Chapter 1: Getting started as a member1-6As long as you are a member of our plan, in most cases, you must not use your red, white, andblue Medicare card to get covered medical services (with the exception of routine clinical researchstudies and hospice services). You may be asked to show your Medicare card if you need hospitalservices. Keep your red, white, and blue Medicare card in a safe place in case you need it later.Note: If you are not entitled to Medicare Part A coverage, hospice services are not covered by theplan or by Medicare.Here’s why this is so important: If you get covered services using your red, white, and blueMedicare card instead of using your UnitedHealthcare member ID card while you are a planmember, you may have to pay the full cost yourself.If your UnitedHealthcare member ID card is damaged, lost, or stolen, call Customer Service rightaway and we will send you a new card. (Phone numbers for Customer Service are printed on theback cover of this
UnitedHealthcare Group Medicare Advantage with Dental and Vision Preferred Provider Organization (PPO) . Y0066_EOC_H2001_816_000_2020_C UHEX20PP4484700_001. January 1, 2020 – December 31, 2020 Evidence of Coverage Your Medicare Health Benefits and Service
