2018 NUSS - Medical Plan

UHC Choice Plus 100 Plan

 
With the Choice Plus 100 plan, you have the flexibility to use in-network or out-of-network providers each time you seek care. However, you can minimize your out-of-pocket
expenses by using in-network providers.
 
Find a Doctor
In-Network Coverage: When you use UHC network providers, you pay a $30 copay for physician office visits (including specialists and urgent care). Preventive care is covered at 100%. All medical and prescription drug copays accumulate toward your annual out-of-pocket maximum.
 
The Choice Plus 100 plan has no deductible for most in-network services. Copays apply for certain services and in some cases are dependent on where the service is received. For example, inpatient hospital services require a $500 per admission copay; outpatient hospital services, including lab and radiology, require a $150 copay.* In addition, after you reach the in-network out-of-pocket maximum of $3,500 for an individual and $7,000 for a family, the Choice Plus 100 plan pays 100% of covered in-network medical charges for the remainder of the calendar year.
 
Whenever you are having diagnostic or preventive tests, be sure to ask your physician if he/she is referring you to a provider who is in-network.
 

Out-of-Network Coverage

Most out-of-network services are covered at 60%** of 190% of the Medicare Maximum Allowable Charge (MAC). For the Choice Plus 100 plan, out-of-network expenses are handled as outlined below:
  • You are responsible for obtaining precertifications from UHC before most non-office visit treatment begins (unless it is an emergency). If you do not request precertification before having inpatient or outpatient surgery and/or certain treatment, you will be subject to a $500 penalty. If you are having trouble finding providers and/or services in the network, please call UHC at 800-232-9357. In an emergency, if you or your covered dependent is admitted to a non-network hospital, you must contact UHC within 48 hours of admission or you will be subject to a $500 penalty.
     
  • Before the Plan starts to pay anything for out-of-network services, you must meet your out-of-network deductible.
     
  • Then the Plan pays coinsurance of 60%** of remaining covered charges up to a maximum of 190% of the Medicare MAC.
     
  • If you reach the out-of-network out-of-pocket maximum, the Plan will pay 190% of the Medicare MAC.
Note: Your out-of-network expenses can be used to satisfy the in-network deductible and in-network out-of-pocket maximum.
 
* No copay for lab and radiology at certain designated NYP locations.
** 70% for outpatient mental health/substance abuse services.

 

Travel Vaccination Coverage

If you are traveling out of the country, travel vaccinations will be covered under the medical plan (for the Choice Plus 80 plan, deductible and coinsurance will apply).
 

Preventive Care


 
MEDICAL & PRESCRIPTION DRUG ID CARDS 
If you newly enroll in medical benefits, you will receive a UHC ID card. This card will include member information for medical and prescription drug coverage. It takes approximately three weeks for new hires to receive an ID card. If you need a temporary ID card sooner, go to www.myuhc.com two weeks after you complete your benefits enrollment to download and print your temporary card. 


Medicare Maximum Allowable Charge (MAC) 

Out-of-network services in the healthcare plans are indexed to 190% of the Medicare MAC. Out-of-network services are covered at 60% of 190% of the Medicare MAC, except for mental health and substance use disorder outpatient counseling and outpatient programs which are covered at 70% of 190% of the Medicare MAC.
 
Here’s an example: Your out-of-network physician charges you $200 for an office visit. The claim submitted to UHC has a billing code of 99212 (office visit for an established patient in ZIP code 10010 in New York City). 190% of the Medicare MAC for this billing code is $95.87. Therefore, $95.87 (not $200) is the basis for the out-of-network reimbursement.
  • If you had not met the out-of-network annual deductible, you would be responsible to pay the full $200, and $95.87 would be applied to the out-of-network deductible.
     
  • If you had already met the out-of-network annual deductible, the Plan would pay the coinsurance of 60% of $95.87, which is $57.22. Your share of the coinsurance is 40% of $95.87, which is $38.35. You are also responsible to pay the amount in excess of the 190% of the Medicare MAC; that is $200 - $95.87 = $104.13. In total, you would pay $38.35 + $104.13 = $142.48, and $38.35 would be applied toward your out-of-pocket maximum.
     
  • If you had met the out-of-network annual out-of-pocket maximum, the medical carrier would pay 190% of the Medicare MAC ($95.87), and you would be responsible for the balance ($104.13).
Charges in excess of 190% of the Medicare MAC (in this example, $104.13) do not count toward the out-of-network out-of-pocket maximum.
 
Important noteImportant! Providers can bill you for any unpaid balance for amounts above these limits,
and you are solely responsible for these payments.
 
  • Any charges exceeding plan limits do not count toward the out-of-pocket maximum, including any charges exceeding 190% of the Medicare MAC.
     
  • You can find out how much you will be reimbursed for out-of-network services before you seek treatment by first asking your physician for the medical “procedure code” along with the associated fee. Then, call UHC’s member services to request an estimate of their reimbursement.
 

Retiree Medical Insurance

You may be eligible for this coverage if you leave the University on or after age 55 and you complete at least 10 years of full-time benefits-eligible service with the University after age 45. To learn more, please contact the Columbia Benefits Service Center at 212-851-7000, Monday through Friday, 9 a.m. to 4 p.m. You may also contact us via email
 
Note: A spouse or dependent is only eligible to enroll if the retiree is a participant or if the retiree is deceased. Spousal coverage will only be offered to a spouse the retiree is legally married to on the date of retirement. Eligible children are covered until age 26 as long as they are full-time students. Qualifying events must be reported within 31 days of the event.