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2016-2017 StudentHealth Plan provided bySaudi Arabian CulturalMission (SACM)Student Guide16COL3547Version Date: March 10, 2017
Good health is essential to your academic success.INTEGRITYUnitedHealthcare remains committed to supportingstudents to ensure they can achieve their academicgoals, and we are uniquely qualified to meet thin this guide, you will find valuable informationabout the services available to you. Please note thatMedical and Dental services are separate from eachother. We recommend you become familiar with thisguide and the corresponding resources for medicaland dental to learn about your plan and how to useyour benefits.PERFORMANCEContentsUHC at a GlanceWelcome to UHCSRYour Medical Coverage - PPO PlanMy Account and Access your Medical ID CardFind a Medical Health Care ProviderWhich provider should I see?DefinitionsGlobal Emergency ServicesTelemedicine by HealthiestYouHospitalization Pre-Admission NotificationSubmit a Claim for Member ReimbursementHow to reach UHC for Medical InformationYour Dental CoverageAccess your Dental ID CardHow to Find a Dental Health Care ProviderHow to reach UHC for Dental InformationYour Vision CoverageID Card for Vision BenefitsHow to Find a Vision Care ProviderHow to reach UHC for Vision InformationOur nationwide networks are robust andhighly competitive, our innovative eligibility andadministrative systems are built specifically tosupport student health benefit plans and ouremployees are dedicated to the needs of theschools and their students.3458991012121314151617171718191919
UHC at a GlanceWhere to find helpful informationOn your home page, www.uhcsr.com/SACM: Medical, Mental Health and Dental Provider Search Pharmacy LocatorFor customer service,please call1-866-808-8461 Benefit Information Details on your medical and dental benefits SACM Student GuideMonday–Friday7:00AM–7:00PM CST Helpful Information Create Account Guide Create/log in to My Account Download the Mobile AppOn your My Account page:Helpful Links Network Medical Provider Search Dental Provider SearchYour home page is: View Current Coveragewww.uhcsr.com/SACM View Personal InformationUse it to access yourbenefit information,including locating aprovider, viewing claims,and other features of yourMy Account page. View/Print/Download/Request ID Card View Claims Information Submit Accident Details Personal Representative Appointment (for authorizing someone toact on your behalf in matters of your benefit plan) Links to Value Added Benefits Global Emergency Services HealthiestYou UHC Dental Message Center My Messages My Documents(See page 8 for details about creating My Account)3
Welcome to UnitedHealthcare StudentResources(UHCSR)UHCSR is the dedicated student health division of UnitedHealthcare (UHC). UHCSR willbe your first point of contact for all questions. Below is where to find helpful information.ProviderSearchBenefitInformationYou can searchfor healthcare preferredproviders online at our websitewww.uhcsr.com/SACM or onyour mobile device with our freeUHCSR Mobile App.You can findyour StudentGuide and otherhelpful information regarding theavailable services as well as generalhealth information and FAQs atwww.uhcsr.com/SACM.AccountInformationLog into your MyAccount pageon our website atwww.uhcsr.com/SACM. From thereyou can download your medical ID card,access medical claims information, seeany messages sent to you, and accessother helpful information.4
Your Medical Coverage - PPO PlanA generous health benefit plan is provided by SACM for its students and their dependents. SACM students arecovered at 100% for Preferred Provider In-Network care. The UHC network is one of America’s largest healthcare networks, with over 800,000 network providers. For questions pertaining to your medical benefits, callCustomer Service at 1-866-808-8461.Your medical plan includes: Doctor office visits and preventive care (routinephysicals, immunizations, cancer screenings)Diagnostic lab and radiology testsVision carePharmacy coverageInpatient and outpatient care Mental health servicesHome health careMaternity careShort-term rehabilitation (physical, occupationaland speech therapy)Emergency and urgent careYour full summary of benefits is listed below. The benefits are provided by your plan sponsor (SACM) and are subject tochange by SACM. A complete description of your benefits and any limitations and exclusions are provided in the SACMBenefits Booklet, Plan Number 2016-1965-1/2.Eligibility ProvisionsStudentsDiplomat or StaffDependentsPlan FeaturesMaximum BenefitDeductibleCoinsuranceNotes on your Benefits PlanAny sponsored Saudi national enrolled in a scholarly program in the United States pursuant to avalid student visa issued by the United StatesAny sponsored Saudi national in the United States on a valid visa serving as a Diplomat or Staff ofthe Saudi Government is eligible to be enrolled in the plan.Dependents of insureds that are in an Eligible Class are also eligible to be covered under the plan.Preferred ProviderOut‐of‐Network ProviderNo Overall Maximum Dollar Limit (Per Covered Person, Per Plan Year) 0 ( Per Covered Person, Per Plan Year ) 10,000 ( Per Covered Person, Per Plan Year )100% except as noted below20% except as noted belowThe Preferred Provider network for this Plan is UnitedHealthcare Choice Plus PPO.If care is received from a Preferred Provider any Covered Medical Expenses will be paid at the Preferred Provider level of Benefits. If aPreferred Provider is not available in the Network Area, Benefits will be paid at the level of Benefits shown as Preferred Provider Benefits. Ifthe Covered Medical Expense is incurred due to a Medical Emergency, Benefits will be paid at the Preferred Provider level of Benefits. CoveredMedical Expense incurred at a Preferred Provider facility by an Out‐of‐Network Provider will be paid at the Preferred Provider level of Benefits.In all other situations, reduced or lower Benefits will be provided when an Out‐of‐Network provider is used.Benefits will be reimbursed at one hundred percent (100%) of billed charges under the following circumstances: 1) All Covered MedicalExpenses for services rendered in Saudi Arabia; and 2) Covered Medical Expenses when due to a Medical Emergency occurring in anycountry outside of the United States. The Plan Deductible will not apply.The Benefits payable are as defined in and subject to all provisions of the Benefits Booklet and any endorsements thereto. Benefits are subjectto the Plan Maximum Benefit unless otherwise specifically stated. Benefits will be paid up to the maximum Benefit for each service asscheduled below. All Benefit maximums are combined Preferred Provider and Out‐of‐Network unless otherwise specifically stated.Plan PaymentsInpatientPreferred ProviderOut‐of‐Network ProviderRoom & Board:Preferred AllowanceUsual and Customary Charges(Includes guest bed and meal trays for adult accompanying a minor while confined as an Inpatient.)Intensive Care:Preferred AllowanceUsual and Customary ChargesHospital Miscellaneous Expense:Preferred AllowanceUsual and Customary ChargesRoutine Newborn Care:Paid as any other SicknessPaid as any other SicknessSurgery:Preferred AllowanceUsual and Customary Charges(If two or more procedures are performed through the same incision or in immediate succession at the same operative session, themaximum amount paid will not exceed 50% of the second procedure and 50% of all subsequent procedure.)Assistant Surgeon Fees:Preferred AllowanceUsual and Customary ChargesAnesthetist Services:Preferred AllowanceUsual and Customary ChargesRegistered Nurse's Services:Preferred AllowanceUsual and Customary ChargesPhysician's Visits:Preferred AllowanceUsual and Customary ChargesPre‐admission Testing:Preferred AllowanceUsual and Customary Charges5
OutpatientPreferred ProviderOut‐of‐Network ProviderSurgery:Preferred AllowanceUsual and Customary Charges(If two or more procedures are performed through the same incision or in immediate succession at the same operative session, themaximum amount paid will not exceed 50% of the second procedure and 50% of all subsequent procedure.)Day Surgery Miscellaneous:Preferred AllowanceUsual and Customary Charges(Day Surgery Miscellaneous charges are based on the Outpatient Surgical Facility Charge Index.)Assistant Surgeon Fees:Preferred AllowanceUsual and Customary ChargesAnesthetist Services:Preferred AllowanceUsual and Customary ChargesPhysician's Visits:Preferred AllowanceUsual and Customary ChargesPhysiotherapy:Preferred AllowanceUsual and Customary Charges(12 visits maximum (Per Plan Year))Medical Emergency Expenses:Preferred AllowanceUsual and Customary Charges 100 Copay per visit 100 Deductible per visit(The Copay/per visit Deductible will be waived if admitted to the Hospital.)(Benefits include the use of the Emergency Room for a non‐emergency Injury or Sickness.)Diagnostic X‐ray Services:Preferred AllowanceUsual and Customary ChargesRadiation Therapy:Preferred AllowanceUsual and Customary ChargesLaboratory Procedures:Preferred AllowanceUsual and Customary ChargesTests & Procedures:Preferred AllowanceUsual and Customary ChargesInjections:Preferred AllowanceUsual and Customary ChargesChemotherapy:Preferred AllowanceUsual and Customary ChargesUnitedHealthcare Pharmacy (UHCP)Usual and Customary ChargesPrescription Drugs: 0 Copay per prescription for Tier 1Ancillary Charge applies when 0 Copay per prescription for Tier 2prescription is dispensed from a 0 Copay per prescription for Tier 3higher tier at the Covered Person'srequest and a chemically equivalentup to a 31 day supply per prescription plus anyprescription drug is available at aAncillary Chargelower tier.(Mail order Prescription Drugs through UHCP with a 0 Copay per prescription plus any Ancillary Chargeup to a 90 day supply per prescription.)OtherPreferred ProviderOut‐of‐Network ProviderAmbulance Services:Preferred AllowanceUsual and Customary ChargesDurable Medical Equipment:Preferred AllowanceUsual and Customary ChargesConsultant Physician Fees:Preferred AllowanceUsual and Customary ChargesDental Treatment:Preferred AllowanceUsual and Customary Charges(Includes benefits for Injury to Sound, Natural Teeth, and treatment of cleft lip and cleft palate only.)Mental Illness Treatment:Paid as any other SicknessPaid as any other SicknessSubstance Use Disorder Treatment: Paid as any other SicknessPaid as any other SicknessMaternity:Paid as any other SicknessPaid as any other SicknessComplications of Pregnancy:Paid as any other SicknessPaid as any other SicknessPreventive Care Services:Preferred AllowanceUsual and Customary Charges(Routine Children Physicals: Includes all services given in connection with the exam. Limited to 7 exams in the first 12 months of life, 3 exams in thesecond 12 months of life, 3 exams in the third 12 months of life, and 1 exam per calendar year thereafter up to age 18.)(Routine Adult Physical Exams: Includes all services given in connection with the exam. Limited to 1 exam per calendar year for adults age 18 and over.)(Routine Gynecological Exams: Includes all services given in connection with the exam. Limited to 1 exam and pap smear per calendar year.)(Mammograms: Unlimited)(Prostate Specific Antigen (PSA): Limited to 1 PSA test per calendar year for males age 40 and over.)(Digital Rectal Exam (DRE): Limited to 1 DRE per calendar year for males age 40 and over.)(Cancer Screening: Limited to 1 flexible sigmoidoscopy and double barium contrast every 5 years. Limited to 1 colonoscopy every 10 years for adults age50 and over.)(Fecal Occult Blood Test: Limited to 1 per calendar year.)(Testing for Tuberculosis.)Reconstructive Breast SurgeryPaid as any other SicknessPaid as any other SicknessFollowing Mastectomy:Diabetes Services:Paid as any other SicknessPaid as any other SicknessHome Health Care:Preferred AllowanceUsual and Customary Charges(Unlimited visits per Policy Year.)Hospice Care:Preferred AllowanceUsual and Customary Charges(Inpatient: 30 days lifetime maximum. Outpatient: 10,000 lifetime maximum.)6
Other (continued)Preferred ProviderInpatient Rehabilitation Facility:Preferred AllowanceSkilled Nursing Facility:Preferred AllowanceUrgent Care Center:Preferred AllowanceHospital Outpatient Facility or Clinic: Preferred AllowanceApproved Clinical Trials:Paid as any other SicknessTransplantation Services:Paid as any other SicknessAcupuncture in Lieu of Anesthesia:Paid as any other SicknessHearing Aids:Preferred Allowance( 3,500 maximum (Per Plan Year). A written prescription is required).Infertility Services:Preferred AllowanceMedical Foods:Preferred Allowance(A written prescription is required.)Ostomy Supplies:Preferred AllowanceTMJ Disorder:Preferred Allowance( 5,000 maximum (Per Plan Year))Repatriation:Benefits provided by UnitedHealthcare Globalor reimbursed by SACMMedical Evacuation:Benefits provided by UnitedHealthcare GlobalOther:Note BelowOut‐of‐Network ProviderUsual and Customary ChargesUsual and Customary ChargesUsual and Customary ChargesUsual and Customary ChargesPaid as any other SicknessPaid as any other SicknessPaid as any other SicknessUsual and Customary ChargesUsual and Customary ChargesUsual and Customary ChargesUsual and Customary ChargesUsual and Customary ChargesBenefits provided by UnitedHealthcare Globalor reimbursed by SACMBenefits provided by UnitedHealthcare GlobalNote BelowSpinal Disorder Treatment: Preferred Allowance / Usual and Customary Charges – (Caused by or related a biochemical or nerve disorders of thespine. Unlimited visits per Plan Year.) Ear Piercing provided in the Physician’s office for Females age 10 and under: Preferred Allowance / Usualand Customary Charges. Treatment for Congenital Defects and Pre‐mature Born Babies: Preferred Allowance / Usual and Customary Charges.Braille Machines: Preferred Allowance / Usual and Customary Charges ( 700 maximum per Plan Year.). Sickle Cell Anemia Testing DuringPregnancy: Preferred Allowance/Usual and Customary Charges. Obesity Treatment: Paid as any other Sickness / Paid as any other sickness.Routine Hearing Exams:Preferred Allowance(Includes one audiometric routine exam per Plan Year.)Usual and Customary Charges7
Sign up for My Account and Access your Medical ID CardContinuously enrolled SACM members were mailed a new UHCSR medical ID card in December2016 to the U.S. mailing address that we have on file. If you’re a new member, you should receiveyour medical card sometime in January 2017.You can visit www.uhcsr.com/SACMCreateAccount to create your MyAccount and download anelectronic copy of your UHCSR medical card. You may also download our UHCSR Mobile App fromyour App Provider so you can have your account information and medical ID card for you and yourdependents (if applicable) readily available on your Smart Phone.Once you’ve created your My Account, justlog in with your user name and password atwww.uhcsr.com/SACM and begin to accessyour account online, at your own convenience.Creating your My Account is easy! Create your account today and: View coverage details View or print your medical ID card Review information about your dental plan Review Message Center electronicnotifications Check Claim status and Explanations ofBenefits (EOB) Review claims letters Search for a preferred provider Provide accident details or PersonalRepresentative Appointment Review your personal information –if we don’t have your U. S. mailingaddress, be sure to update it in theSACM Database, through the Ministryof Higher Education student portal/Safeer as soon as possible.8Visit www.uhcsr.com/SACM and clickthe Create an Account linkFollow the onscreen prompts – you’llneed your First and Last Name, Dateof Birth and your Saudi National ID.Create your user name. Youruser name must contain 6 – 30alphanumeric characters. Verify youremail address and submit.You will receive a return email witha pin that you will use to verify youraccount and create a password.Your password must have 8-12characters and include at leastthree of the following: an uppercasecharacter, a lowercase character,a numeric character (0-9), and aspecial character (e.g., *, , , etc.).
How to Find a Medical Health Care ProviderChoose a UnitedHealthcare medical provider to help maximize health care dollars and lower out-of-pocket costs.Use the UHCSR Mobile App or go to www.uhcsr.com/SACM. Click the links under “Search for a Provider”. Or callCustomer Service at 866-808-8461.1. Access your SACM Welcome page at www.uhcsr.com/SACM2. In the Search for a Provider section click the Medical - UHC Choice Plus link3. Click Change Location and specify a ZIP code or city/state to narrow down the location. Click OK.4. In the Search box, specify Doctor Name or Specialty, Facility Name, Clinic Name, or Medical Group Name.Click SEARCH. You may also click the Find Health Care by Category buttons below the Search box to search byPeople, Places, Tests and Imaging, Services and Treatments or Care by Condition.5. Follow the prompts to further refine your search criteria. The search results will indicate the providers’ address, phone number and other details.Which provider should I see?Sometimes it may be difficult to decide if a sudden illness or injury needs immediate emergency care. Choosingthe right health setting - Primary Care Physician, Urgent Care, or Emergency Room is important; knowing whichprovider to see, depending on the medical situation, can save you time and money.Primary Care PhysicianWhen you or a loved one is hurt, you want the best care. Your primary care physician knows you and your healthhistory. He or she can access your medical records. And, he or she can provide you follow-up care or refer you tospecialists. If it’s not urgent, it’s usually best to go to your own physician’s office.Urgent CareSometimes you may need care fast. But, your Primary Care Physician may be unavailable. You may want to tryan urgent care center. They can treat many minor ailments. Chances are, you won’t have to wait as long as at anemergency room. You may pay less, too.An urgent care center can help with: Sprains & Strains Minor broken bones (example: finger) Minor infections Small cuts Sore throats RashesEmergency RoomsYou may be tempted to go to an emergency room (ER). But, this maynot be the best choice. At the ER, true emergencies are treated first.Other cases must wait--sometimes for hours. And, it may cost you more.Go to an ER for: Heavy bleeding Large open wounds Sudden change in vision Chest pain Sudden weakness or trouble talking Major burns Severe head and spinal injuries Difficulty breathing Major broken bones9
DefinitionsBelow, you will find a definition of what’s considered a medical emergency for the purpose of plan benefits inaddition to other relevant terms that will help you navigate your benefit plan.ANCILLARY CHARGE means a charge, in addition to the Copayment and/or Coinsurance, that the CoveredPerson is required to pay when a covered Prescription Drug Product is dispensed at the Covered Person’s orthe Physician’s request, when a Chemically Equivalent Prescription Drug Product is available on a lower tier.For Prescription Drug Products from Network Pharmacies, the Ancillary Charge is calculated as the differencebetween the Prescription Drug Cost or MAC list price for Network Pharmacies for the Prescription Drug Producton the higher tier, and the Prescription Drug Cost or MAC list price of the Chemically Equivalent Prescription DrugProduct available on the lower tier.BENEFITS means Plan payments for Covered Medical Expenses, subject to the terms and conditions of the Planand any Addendums and/or Amendments.CLAIMS ADMINISTRATOR OR ADMINISTRATOR means United HealthCare Services, Inc., and its affiliates,which provide certain claim administration services for the Plan.COINSURANCE means the percentage of Covered Medical Expenses that you must pay.COPAY/COPAYMENT means a spec
Mar 10, 2017 · A generous health benefit plan is provided by SACM for its students and their dependents. SACM students are covered at 100% for Preferred Provider In-Network care. The UHC network is one of America’s largest health care networks, with over 800,000 network providers. For questions pertaining to your medical benefits, callFile Size: 818KB
