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UK-HMO Regional Service Area
FREQUENTLY ASKED QUESTIONS & ANSWERS
For Plan Year July 1, 2005 - June 30, 2006

This information is not a contract. It is a partial summary of benefits and services. For complete details on covered services, exclusion and benefit limitations, refer to the Certificate of Coverage.

Table of Contents
  1. General Information
  2. Benefits / Coverage
  3. Dependent Care / Coverage
  4. Providers (use of Primary Care Physician)
  5. Rates
  6. Service Area / Out of Area Coverage
  7. Women’s Health

QUESTIONS & ANSWERS
A.  GENERAL INFORMATION: Index

  1. WHAT IS UK-HMO'S RELATIONSHIP WITH HUMANA?

  • The UK-HMO plan is renting a Humana network of providers for services not available at UK Chandler Medical Center or UK Good Samaritan hospitals and contracting with Humana to provide administrative services.

 

    2.  WHO IS ELIGIBLE FOR THE UK-HMO REGIONAL

         SERVICE AREA PLAN?

  • All full-time active employees and their dependents who live within the Regional Service Area. Also, any all full-time active UK employees that live in a county in which the Indemnity Plan is offered, but work in a Regional Service Area county can choose the RSA plan. 
  1. WHAT ARE THE BOUNDARIES OF THE REGIONAL SERVICE AREA?
  • You must live in the counties below or live in a county in which the Indemnity Plan is offered, but work in an RSA county to participate in the UK-HMO Regional Service Area Plan: 

     Adair, Ballard, Barren, Bath, Bell, Boone, Boyd, Boyle, Bracken, Breathitt, Bullitt, Butler, Caldwell, Calloway, Carlisle, Carroll, Campbell, Carter, Casey, Christian, Clay, Clinton, Crittenden, Cumberland, Edmonson, Elliott, Estill, Fleming, Floyd, Fulton, Gallatin, Garrard, Grant, Graves, Green, Greenup, Harlan, Harrison, Hart, Henry, Hickman, Hopkins, Jackson, Jefferson, Johnson, Kenton, Knott, Knox, Laurel, Lawrence, Lee, Leslie, Letcher, Lewis, Lincoln, Livingston, Logan, Lyon, Magoffin, Marion, Marshall, Martin, Mason, McCracken, Menifee, Metcalfe, Monroe, Montgomery, Morgan, Nicholas, Oldham, Owen, Owsley, Pendleton, Perry, Pike, Powell, Robertson, Rockcastle, Rowan Russell, Shelby, Spencer, Taylor, Trigg, Trimble, Warren, Washington, Whitley, or Wolfe
  1. WHEN IS UK OPEN ENROLLMENT?
  • Open enrollment is held once a year, usually in April.
  1. MY SPOUSE AND I BOTH WORK FOR UK. CAN WE OBTAIN THE “COMBINED CREDIT”?
  • Yes, this benefit is called the “combined-credit.” The Employee + Family /Combined credit tier combines the Single credit and the Employee + Children credit, resulting in the same overall premium amount being deducted as would be deducted if each employee enrolled in a separate plan.

    The advantage of choosing this tier is seen by those enrolled in the PPO and Indemnity plans that have individual and family deductibles. By enrolling all members of the family on one plan, employees may benefit from a lower overall deductible.
  1. I’M MOVING AND NEED TO KNOW IF MOVING WILL AFFECT MY HEALTH PLAN COVERAGE?
  • If you (or any of your dependents) are moving to a residence within the UK-HMO Regional Service Area, you need to update your address with each of the following:  1) your department (see your department administrator or business officer); 2) your retirement carrier; 3) the University (address change form available online at www.uky.edu/eForms - find Address Change Form under “A” in alphabetical listings).

     If you (or any of your dependents) are moving outside of the UK-HMO Regional Service Area, you may become ineligible for the UK-HMO Regional Service Area Plan and have 30 days to notify the UK Employee Benefits Office in writing. You will need to fill out the "Health Benefit Enrollment Form", changing your address, and selecting a different health care plan at that time. The form should be sent to UK Employee Benefits at 112 Scovell Hall, Lexington, KY 40506-0064 or UK Benefits, 321 Wethington Building, Lexington, KY  40536.
  1. CAN I CHANGE FROM MY EMPLOYEE ONLY TO EMPLOYEE PLUS 1 OR FAMILY OR VISA VERSA DURING THE YEAR?
    2.
  • The choices you make during Open Enrollment, or as a new employee, remain in place from July 1, 2007 through June 30, 2008. You cannot add or drop coverage until the next Open Enrollment period in April 2008 (for the plan year beginning July 1, 2008) unless you have a change in family status or experience another “qualifying event.”  The following changes would allow you to make changes to your current benefits during the plan year (mid-year changes must be requested within 30 days of the events.
  • Birth or Adoption (Copy of footprints from hospital or copy of adoption papers must be submitted to UKHR); Marriage (Copy of marriage certificate must be submitted to UKHR); Divorce (Copy of final court decree must be submitted to UKHR); Employement status (Statement on company letterhead stating changes (with begin and end dates).
B.  BENEFITS / COVERAGE Index
  1. WILL MY MEDICAL CONDITIONS, PRESCRIPTION, AND DURABLE MEDICAL EQUIPMENT BE COVERED?
  • We cannot guarantee or make a determination of a future claim, but this is a benefit available to you. (This will depend on benefit, provider, etc.)
  1. IS ORAL SURGERY OR OTHER DENTAL PROCEDURES COVERED?
  • Oral surgery is a covered benefit under specific circumstances.  Please refer to the Certificate of Coverage (COC) for details.
  1. ARE EYEGLASSES OR CONTACT LENSES COVERED?
  • No.
  1. IS COSMETIC SURGERY COVERED? OR RECONSTRUCTIVE SURGERY? WHAT IF IT'S REQUIRED DUE TO CONGENITAL DEFECTS?
  • Some procedures are covered but must have prior authorization; your physician must request Authorization, provide the medical information and request a determination prior to performing any of these procedures.
  1. ARE PODIATRY SERVICES COVERED?
  • Yes,  See the certificate of coverage, (exclusions are listed for foot-related services).
  1. IS TMJ OR CMJ COVERED?
  • Yes - with prior authorization.
  1. I’M GOING OUT OF THE COUNTRY AND NEED TO GET SOME IMMUNIZATIONS, WILL UK-HMO COVER THEM?
  • No - UK-HMO does not provide coverage for office visits; examinations; treatments; immunizations; and tests relating to requirements or documentation of health or medical status for employment; insurance; travel; or school purposes, or for legal proceedings.
C.  DEPENDENT CARE / COVERAGE: Index
  1. WHO IS AN ELIGIBLE DEPENDENT?

Eligible dependents include:

  • your spouse
  • your unmarried dependent children up to age 25 who are dependent on you for support
  • your mentally or physically disabled children of any age who were or became disabled before the age limit and who were already covered by your plan
  • your sponsored dependent
  • Unmarried children of your adult sponsored dependent up to age 25 and who reside in the employee's household.
  1. WHAT IS THE AGE LIMIT FOR DEPENDENT CHILDREN?
  • The age limit is 25 years of age Coverage ends at the end of the month in which the child their 25th birthday.
  1. I HAVE A CHILD WHO IS MENTALLY AND PHYSICALLY INCAPACITATED. WILL YOU COVER THIS CHILD?
  • Eligibility will continue past the age limit for Dependents who are totally disabled and who are Covered Persons upon reaching the age limit. The Dependent must have been totally disabled before reaching the age limit. A Physician must certify that the Dependent is totally disabled. We may require proof of the disability from time to time. A total disability is a condition that results when any physical handicap or mental retardation prevents a Dependent from engaging in substantial gainful activity. 

    The disability must be expected to result in death or be of continuous or indefinite duration. We are the final authority for determining whether a Dependent is totally disabled.
  1. CAN I COVER MY MOTHER AS A DEPENDENT?
  • No - Your parent is not considered to be an eligible dependent for health coverage.
  1. MY DAUGHTER WHO IS 16 BECAME PREGNANT. WILL YOU COVER MY DAUGHTER’S PREGNANCY AND DELIVERY?
  • Yes
  1. WILL YOU COVER MY DAUGHTER’S CHILD?
  • No- Unless you are awarded legal guardianship of the child.
  1. MY STEP-CHILDREN DO NOT LIVE WITH ME. CAN I COVER THEM UNDER MY PLAN?
  • Yes - If you are by court order financially responsible for them and if they reside within the UKHMO Regional Service Area.
  1. MY CHILD IS A FULL TIME STUDENT AT A UNIVERSITY OUTSIDE THE REGIONAL SERVICE AREA. WHAT COVERAGE WILL SHE HAVE WHILE AT SCHOOL?
  • If your Dependent attends school outside the Service Area, all Plan Delivery System Rules apply. Routine services must be received from a UK-HMO LSA Participating Provider. See above for Emergency and Urgent Care coverage.  Unmarried, full-time students are eligible for coverage until age 25.
D.  PROVIDERS (USE OF PRIMARY CARE PHYSICIAN): Index
  1. WILL I BE ABLE TO KEEP MY PRESENT DOCTOR?
  • Please refer to the UK-HMO website provider search to determine if your physician is a participating provider. If you choose UK-HMO, benefits are payable only if network providers are used.
  1. DO I NEED A REFERRAL FOR ANY KIND OF VISIT TO A DOCTOR?
  • No - The UK-HMO Regional Service Area Plan does not require that you choose a Primary Care Provider and obtain referrals for specialty care. However, we encourage you to establish a relationship with a Primary Care Physician. Doing so will enable the physician to better serve your health care needs should you become ill or injured. 
  1. DO I MAKE THE DECISION ON THE REFERRAL DOCTOR FOR SPECIALTY CARE OR IS THIS DECIDED BY THE PCP?
  • The PCP is responsible to coordinate all of the patient’s care. The member can choose to see any specialty care provider in your RSA Service Area (the county in which you live or an immediately adjacent RSA County), however, we strongly encourage you to see your PCP to allow for better coordination of care. Any specialty care that is not available in your RSA service area must be provided by the UK Chandler Medical Center.
  1. IF MY PCP IS UNABLE TO SEE ME, CAN I SEE ANOTHER PROVIDER IN THE CLINIC?
  • Yes - You may see another doctor in their practice as well as Urgent Treatment Centers for an illness or injury.
  1. IF A PARTICIPATING HOSPITAL CANNOT PROVIDE A SERVICE THAT I NEED, CAN I GO TO ANY HOSPITAL?
  • Work through your PCP for direction. You are able to go to any hospital in your RSA Service Area, but your PCP may only practice at a specific one. Any specialty care that is not available in your service area should be provided by the UK Chandler Medical Center.
E.  RATES: Index
  1. HOW MUCH IS THE UK-HMO PLAN?
  • This cost changes yearly.  Please refer to the UK Benefits to determine this cost by calling 257-9519 and choosing 3 for benefits and then 1 to speak with a customer service representative.  You may also find this on the UK Benefits website at www.uky.edu/HR/benefits.
F.  SERVICE AREA: Index
  1. WHAT ARE THE BOUNDARIES OF THE REGIONAL SERVICE AREA?
  • You must live in the counties below or live in a county in which the Indemnity Plan is offered, but work in an RSA county to participate in the UK-HMO Regional Service Area Plan: Adair, Ballard, Barren, Bath, Bell, Boone, Boyd, Boyle, Bracken, Breathitt, Bullitt, Butler, Caldwell, Calloway, Carlisle, Carroll, Campbell, Carter, Casey, Christian, Clay, Clinton, Crittenden, Cumberland, Edmonson, Elliott, Estill, Fleming, Floyd, Fulton, Gallatin, Garrard, Grant, Graves, Green, Greenup, Harlan, Harrison, Hart, Henry, Hickman, Hopkins, Jackson, Jefferson, Johnson, Kenton, Knott, Knox, Laurel, Lawrence, Lee, Leslie, Letcher, Lewis, Lincoln, Livingston, Logan, Lyon, Magoffin, Marion, Marshall, Martin, Mason, McCracken, Menifee, Metcalfe, Monroe, Montgomery, Morgan, Nicholas, Oldham, Owen, Owsley, Pendleton, Perry, Pike, Powell, Robertson, Rockcastle, Rowan Russell, Shelby, Spencer, Taylor, Trigg, Trimble, Warren, Washington, Whitley, or Wolfe
  1. IF AN ENROLLEE WORKS IN A UK-HMO SERVICE AREA, MAY HE/SHE TAKE A PLAN OFFERED THERE?
  • The live or work option is only available to persons who have the UK Indemnity plan option which is offered to those members who live out of state.  So if you live in Indiana, but work in Louisville, you may choose the plans that are available in Jefferson County where you work or in Indiana where you live. 
  1. DO BOTH MY SPOUSE AND I HAVE TO LIVE IN YOUR SERVICE AREA?
  • Yes.
  1. MY CHILD IS A FULL TIME STUDENT AT A UNIVERSITY OUTSIDE THE REGIONAL SERVICE AREA. HOW WILL HE/SHE BE COVERED?
    2.
  • If your Dependent attends school outside the Service Area, all Plan Delivery System Rules apply. Routine services must be received from a UK-HMO LSA Participating Provider. See above for Emergency and Urgent Care coverage.  Unmarried, full-time students are eligible for coverage until age 25.
  1. IF I AM TRAVELING AND GET SICK, WHAT SHOULD I DO? WILL TREATMENT BE COVERED BY UK-HMO?
  • If you feel you have an Emergency Medical Condition, you should go to a participating Emergency Room. If your condition makes travel to a UK-HMO RSA participating facility unsafe or if you are out of the Service Area, go to the nearest emergency medical facility.  If necessary, call 911. It is recommended that you notify your personal physician within 24 hours or as soon as reasonably possible. Follow-up care is not considered emergency care.
  1. DO YOU COVER EMERGENCIES OUT OF THE COUNTRY?
  • Yes – When you are traveling out of the Service Area, you are covered for urgent or emergent care only.  Most countries outside the United States may require that you pay for these services and get reimbursement when you return.  Be sure to obtain copies of your medical records and the bill in US currency.  Medical Records also need to be translated prior to submission if they are in a foreign language.
  1. I’M DIVORCED AND MY CHILD LIVES WITH THEIR CUSTODIAL PARENT OUTSIDE OF THE REGIONAL SERVICE AREA.  CAN THEY BE COVERED BY THE UK-HMO REGIONAL SERVICE AREA?
  • No - Both the member and their dependents must reside within the Regional Service Area in order to be eligible for coverage.
G.  WOMEN’S HEALTH: Index
  1. IF I HAVE A NEW BABY, WILL YOU COVER THE BABY AUTOMATICALLY?
  • Yes - Your doctor must be a UK-HMO participating provider. Your newborn will be covered automatically for the first 5 days of newborn nursery regardless of whether the child is placed on the UK-HMO Plan. However, you must add the baby within 30 days in order to have the baby covered from the date of birth by filling out a "Health Benefits Enrollment Form" and sending it to the UK Employee Benefits Office, 112 Scovell Hall, Lexington, KY 40506-0064. If on a single or employee plus one (spouse) plan, you will need to change to either employee plus children or family coverage. You will not be able to add the baby after the 30 days have lapsed until the next open enrollment period. 
  1. HOW LONG WILL I BE COVERED IN THE HOSPITAL FOR HAVING A BABY?
  • The duration of routine inpatient maternity care for a mother is determined by her physician based upon medical necessity.
  1. WILL I BE CHARGED SEPARATE FEES FOR PRENATAL CARE, LABOR AND DELIVERY, AND POSTPARTUM CARE?
  • No - One global fee shall be charged for all maternity care and is covered by the plan. There is a $10 one-time office visit co-payment for the physician services and a $100 inpatient co-pay when you are admitted for the delivery.
  1. IF I ADOPT A CHILD, WHEN WILL COVERAGE BEGIN?
  • The adoption date of the child. You must complete a change form obtained from Employee Benefits and returned to them within 30 days in order to have the child covered. You must also submit the adoption papers with this form to add the child to your plan.
  1. ARE THE ANNUAL OB/GYN VISITS COVERED? THE PAP SMEAR?
  • Yes - When performed by a participating provider.   If you obtain your pap smear from an OB/GYN, for your annual exam only, you will not have a co-payment as this visit is considered the same as a PCP visit.
  1. IS INFERTILITY A COVERED BENEFIT?
  • No - No coverage is provided for infertility services.  No coverage is provided for reversal or any attempted reversal of a previously performed sterilization.
  1. DOES UK-HMO PROVIDE COVERAGE FOR WELL CHILD CARE?
  • Yes - up to age 6 with annual check-ups thereafter.
  1. ARE MAMMOGRAMS COVERED?
  • Yes
  1. IF I AM PREGNANT, WILL UK-HMO COVER MY DELIVERY AND CHILD?
  • Yes - Your doctor must be a UK-HMO participating provider and the delivery must occur at the UK-HMO participating hospital.  There is a $10 specialty co-payment on the initial visit only for pregnancy and a $100 co-pay upon admission for the delivery.
 

This page was last updated on 7/1/09 .  If you have questions or comments about this web page, please send e-mail to Carol Pelfrey