UK-HMO
 

UK Health Services

UK-HMO PLAN

FREQUENTLY ASKED QUESTIONS & ANSWERS

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

Table of Contents

QUESTIONS & ANSWERS

A. General Information
B. Benefits/Coverage
C. Dependent Care/Coverage
D. Providers (use of Primary Care Physician)
E. Rates
F. Service Area/Out of Area Coverage
G. Women's Health

A. GENERAL INFORMATION

1. WHAT IS UK-HMO'S RELATIONSHIP WITH ANTHEM?
The UK-HMO plan is renting Anthem's network of providers for services not available at UK Chandler Medical Center or UK Good Samaritan hospitals and contracting with Anthem to provide administrative services.
2. WHO IS ELIGIBLE FOR THE UK-HMO?
A) UK-HMO PLAN?
All full-time active employees and their dependents who live within a 50 driving mile radius of the University of Kentucky Chandler Medical Center or in one of the following counties (Anderson, Bourbon, Clark, Fayette, Franklin, Jessamine, Madison, Mercer, Scott or Woodford).
3. WHEN IS UK OPEN ENROLLMENT?
Open enrollment is held once a year, which is usually held for 3 weeks at the end of April into May.
4. 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 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 either online through myUK or by filling out the 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 Service Area, you become ineligible for the UK-HMO 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 Benefits at 112 Scovell Hall, Lexington, KY 40506-0064 or UK Benefits, 321 Wethington Building, Lexington, KY 40536.  You can also do this on-line through myUK.

5. CAN I CHANGE FROM EMPLOYEE ONLY TO EMPLOYEE PLUS 1 OR FAMILY OR VISA VERSA DURING THE YEAR?

The changes you make during Open Enrollment, or as a new employee, remain in place for the entire plan year (July through June). You cannot add or drop coverage until the next Open Enrollment period in April.  Changes made during open enrollment go into effect July 1st following Open Enrollment.  If you have a  "qualifying event", you may be eligible to make a change during the year. 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 event). 

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B. BENEFITS / COVERAGE

1. WILL MY MEDICAL CONDITIONS, PRESCRIPTION, AND DURABLE MEDICAL EQUIPMENT (DME) 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 service, the provider, etc.)
2. 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.
3. ARE EYEGLASSES OR CONTACT LENSES COVERED?
These are not covered by UK-HMO.  UK offers an Eyemed plan you can purchase which will cover these services.
4. 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.
5. ARE PODIATRY SERVICES COVERED?
Yes. See the certificate of coverage, (exclusions are listed for some foot-related services).
6. IS TMJ OR CMJ COVERED?
These are covered under certain circumstances with prior authorization.
7. I'M GOING OUT OF THE COUNTRY AND NEED TO GET SOME IMMUNIZATIONS, WILL UK-HMO COVER THEM?
UK-HMO does not provide coverage for office visits, examinations, treatments, immunizations and tests relating to requirements for employment, insurance, travel, school purposes, or for legal proceedings.
8. IS MY CHILD'S EYE EXAM FOR SCHOOL COVERED?
UK-HMO covers the eye exam that is provided by the PCP during his/her annual exam which does not satisfy the requirements for the school eye exam.  This would be covered by Eyemed Insurance if you chose this as an insurance option.

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C. DEPENDENT CARE / COVERAGE

1. WHO IS AN ELIGIBLE DEPENDENT?
Eligible dependents include:
  • your spouse
  • your children up to age 26
  • your mentally or physically disabled children of any age who were or became disabled and who were already covered by your plan.
  • your sponsored dependent
  • child of your adult sponsored dependent up to age 26 and who reside in the employee's household
WHAT IS THE AGE LIMIT FOR DEPENDENT CHILDREN?
The age limit is 26 years of age as long as the child is the member's dependent. Coverage ends at the end of the month in which the child reaches their 25th birthday.
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.
CAN I COVER MY MOTHER AS A DEPENDENT?
No - Your parent is not considered to be an eligible dependent for health coverage.
MY DAUGHTER WHO IS 16 BECAME PREGNANT. WILL YOU COVER MY DAUGHTER'S PREGNANCY AND DELIVERY?
Yes
WILL YOU COVER MY DAUGHTER'S CHILD?
No - Unless you are awarded legal guardianship of the child.
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 UK-HMO Service Area.  If they reside outside the UK-HMO Service Area, you would want to choose another UK plan that would cover them where they live.
MY CHILD IS A FULL TIME STUDENT AT A UNIVERSITY OUTSIDE THE UK-HMO 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 Participating Provider.   They would be covered only for Emergent care in the area they are attending school.

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D. PROVIDERS (USE OF PRIMARY CARE PHYSICIAN):

1. WILL I BE ABLE TO KEEP MY PRESENT DOCTOR?
Please refer to the UK-HMO Provider Directory on the front page of the website to determine if your physician is a participating provider. If you choose UK-HMO, benefits are payable only if network providers are used. There are no out of network benefits other than for emergent care.
2. DO I NEED A REFERRAL FOR ANY KIND OF VISIT TO A DOCTOR?
No referrals are required by UK-HMO.  The UK-HMO 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.
3. DO I MAKE THE DECISION ON THE REFERRAL DOCTOR FOR SPECIALTY CARE OR IS THIS DECIDED BY THE PCP?
Your Primary Care Physician is responsible to coordinate your care. However, you can choose any UK-HMO participating provider.
4. IF MY PCP IS UNABLE TO SEE ME, CAN I SEE ANOTHER PROVIDER IN THE CLINIC?
Yes - You may see another doctor in the KY Clinic as well as participating Urgent Treatment Centers for illness or injury.

You will pay an urgent care co-payment at a participating Urgent Treatment Center or a UK Twilight Co-pay in the UK Pediatrics Twilight Clinic.
5. IF UK HOSPITAL CANNOT PROVIDE A SERVICE THAT I NEED, CAN I GO TO ANY HOSPITAL?
Any specialty care that is not available at UK Hospital must be pre-authorized prior to obtaining the service to determine if that would be allowed. Work through your UK participating physician for direction.

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E. RATES

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.

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F. SERVICE AREA

1. WHAT ARE THE BOUNDRIES OF THE UK-HMO SERVICE AREA?
You must live in the following counties or within a 50 driving mile radius of the University of Kentucky Chandler Medical Center to participate in UK-HMO Lexington Service Area Plan: Anderson, Bourbon, Clark, Fayette, Franklin, Jessamine, Madison, Mercer, Scott or Woodford.
2. DO BOTH MY SPOUSE AND I HAVE TO LIVE IN YOUR SERVICE AREA?
Yes - if both are being covered by your health care plan.
5. MY CHILD IS A FULL TIME STUDENT AT A UNIVERSITY OUTSIDE THE UK-HMO SERVICE AREA. HOW WILL HE/SHE BE COVERED?
If your Dependent attends school outside the Service Area, all Plan Delivery System Rules apply. Routine services must be received from a UK-HMO Participating Provider.   They would be covered only for Emergent care in the area they are attending school.
6. 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 the UK Emergency Room. If your condition makes travel to the UK Emergency Room unsafe or if you are out of the Service Area, you can call the 24/7 NurseLine phone number on the back of your ID card (1-888-279-5378) or 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.
7. DO YOU COVER EMERGENCIES OUT OF THE COUNTRY?
Yes - When you are traveling out of the Service Area, you are covered for emergent care only. UK-HMO members are covered by Anthem BlueCare Worldwide with your UK-HMO card.  Again this is only emergent coverage but Anthem has a network in some foreign countries with participating providers.  If you can utilize a participating provider for this emergent care, Anthem would be able to pay them directly.  If not, once you notify Anthem BlueCare Worldwide that you are in the hospital, they would try to negotiate with the facility to have them accept Anthem's payment for this emergent care.  Worst case scenario, you may have to 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. Attached is the Anthem BlueCare pamplet and Anthem BlueCare reimbursement form
8. I'M DIVORCED AND MY CHILD LIVES WITH THEIR CUSTODIAL PARENT OUTSIDE OF THE UK-HMO SERVICE AREA. CAN THEY BE COVERED BY THE UK-HMO?
No - Both the member and their dependents must reside within the UK-HMO Service Area in order to be eligible for coverage.

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G. WOMEN'S HEALTH

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 for any other services. You would need to submit a "Health Benefits Enrollment Form" to the UK Employee Benefits Office, 112 Scovell Hall, Lexington, KY 40506-0064. You must also submit a copy of the baby's footprint certificate from the hospital or the birth certificate with this enrollment form. 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.

2. 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.  UK-HMO will cover for your stay as long as it is deemed medically necessary.

3. 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 will be an inpatient co-pay applied when you are admitted for the delivery.

4. IF I ADOPT A CHILD, WHEN WILL COVERAGE BEGIN?

Contact UK Employee Benefits at (859) 257-9519, option 3, option 1, to determine when coverage will begin.  You must complete a change form obtained from Employee Benefits and return it 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.

5. 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.

6. IS INFERTILITY A COVERED BENEFIT?

No coverage is provided for infertility services. No coverage is provided for reversal or any attempted reversal of a previously performed sterilization.

7. DOES UK-HMO PROVIDE COVERAGE FOR WELL CHILD CARE?

Yes - up to age 6 with annual check-ups thereafter.

8. ARE MAMMOGRAMS COVERED?

Yes

9. 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 Hospital. There will be an inpatient co-pay applied upon admission.

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