Basic Plan SPD >> Footnotes

1   Hospital/facility is a fully licensed acute-care general facility that has all of the following on its own premises:

• a broad scope of major surgical, medical, therapeutic and diagnostic services available at all times to treat almost all illnesses, accidents and emergencies

• 24-hour general nursing service with registered nurses who are on duty and present in the hospital at all times

• a fully staffed operating room suitable for major surgery, together with anesthesia service and equipment (the hospital must perform major surgery frequently enough to maintain a high level of expertise with respect to such surgery in order to ensure quality care)

• assigned emergency personnel and a “crash cart” to treat cardiac arrest and other medical emergencies

• diagnostic radiology facilities

• a pathology laboratory, and

• an organized medical staff of licensed doctors.

For pregnancy and childbirth services, the definition of “hospital” includes any birthing center that has a participation agreement with UHC.

For kidney dialysis treatment, a facility in New York State qualifies for in-network benefits if the facility has an operating certificate issued by the New York State Department of Health and participates with UHC.

UHC does not recognize as hospitals: nursing or convalescent homes and institutions; rehabilitation facilities (except as noted above), institutions primarily for rest or for the aged, spas, sanitariums, infirmaries at schools, colleges or camps.

2   Outpatient surgery includes hospital surgical facilities, surgeons and surgical assistants; chemotherapy and radiation therapy, including medications, in a hospital outpatient department, doctor’s office or facility (medications that are part of outpatient hospital treatment are covered if they are prescribed by the hospital and filled by the hospital pharmacy). Same-day, ambulatory or outpatient surgery (including invasive diagnostic procedures) means surgery that does not require an overnight stay in a hospital and:

• is performed in a same-day or hospital outpatient surgical facility

• requires the use of both surgical operating and postoperative recovery rooms

• does not require an inpatient hospital admission, and

• would justify an inpatient hospital admission in the absence of a same-day surgery program.

• Surgery to place a cochlear implant is also covered by the Plan. Cochlear implantation can either be an inpatient or outpatient procedure.

3    Kidney dialysis treatment (including hemodialysis and peritoneal dialysis) is covered in the following settings until Medicare becomes primary for end-stage renal disease dialysis (which occurs after 30 months):

• at home, when provided, supervised and arranged by a doctor and the patient has registered with an approved kidney disease treatment center (not covered: professional assistance to perform dialysis and any furniture, electrical, plumbing or other fixtures needed in the home to permit home dialysis treatment), or

• in a hospital-based or free-standing facility.

4    Skilled nursing facility means a licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Skilled nursing facilities are useful when you do not need the level of care a hospital provides, but you are not well enough to recover at home. The Plan covers inpatient care in a skilled nursing facility, for up to 10 days per calendar year of inpatient care for IV antibiotics or for sub-acute rehabilitation from surgery or for wound care.

5    Hospice care is for patients who are diagnosed as terminally ill. Up to 180 days per covered person’s lifetime of hospice care are covered in full in-network only. The Plan covers hospice services when the patient’s doctor certifies that the patient is terminally ill and the hospice care is provided by a hospice organization certified by the state in which the hospice organization is located. Hospice care services include:

• up to 12 hours a day of intermittent nursing care by an RN or LPN

• medical care by the hospice doctor

• drugs and medications prescribed by the patient’s doctor that are not experimental and are approved for use by the most recent “Physicians’ Desk Reference”

• approved drugs and medications

• physical, occupational, speech and respiratory therapy when required

• lab tests, X-rays, chemotherapy and radiation therapy

• social and counseling services for the patient’s family, including bereavement counseling visits for up to one year following the patient’s death (if eligible)

• medically necessary transportation between home and hospital or hospice

• medical supplies and rental of durable medical equipment, and

• transportation between home and hospital or hospice.

6    Home health care means services and supplies including nursing care by a registered nurse (RN) or licensed practical nurse (LPN) and home health aid services. The Plan covers up to 40 home health care visits per calendar year. This limit includes IV infusion, wound care or to allow earlier discharge from a hospital.

7    Home infusion therapy, a service sometimes provided during home health care visits.

8    Emergency room treatment benefits are limited to the initial visit for emergency care. An in-network provider (not an emergency room of a participating hospital) must provide all follow-up care for you to receive maximum benefits. Also remember to contact UHC within 48 hours after an emergency hospital admission, as described on page 16, to pre-notify any continued stay in the hospital. If it is a non-participating hospital, you will need to file a claim in order to be reimbursed for your e

9    Ambulance services (land or air) are covered in an emergency and in other situations when it is medically appropriate (such as taking a patient home when the patient has a major fracture or needs oxygen during the trip home). Ambulance service by air is covered in an emergency if ground transportation is impossible or would put your life or health in serious jeopardy (such as when you need to go to a distant hospital because the nearest hospital you can get to in a land ambulance cannot help you, or using land transportation would pose an immediate threat to your health).ligible expenses.

10    Preventive care under the Plan includes routine physicals, subject to limits shown on page 19. Eligible expenses include X-rays, laboratory or other tests given in connection with the exam and materials for immunizations for infectious diseases. Childhood and adult immunizations are covered as recommended by The Guide to Clinical Preventative Services/ Recommendations of the U.S. Preventative Services Task Force (USPSTF).

11    Well-child care covers visits to a pediatrician, family practice doctor, nurse or licensed nurse practitioner. Regular checkups may include a physical examination, medical history review, developmental assessment, guidance on normal childhood development and laboratory tests. The tests may be performed in the office or a laboratory and must be within five days of the doctor's office visit. The number of well-child visits covered per year depends on your child’s age (see page 19). Covered immunizations include: Diphtheria, tetanus and pertussis (DtaP), Hepatitis B, Haemophilus influenza Type B (Hib), Pneumococcus (Pcv), Polio (IPV), Measles, mumps and rubella (MMR), Varicella (chicken pox), Tetanus-diphtheria (Td), Hepatitis A and influenza for certain patients, other immunizations as determined by the American Academy of Pediatrics, Superintendent of Insurance and the Commissioner of Health in New York State or the state where your child lives.

12    Services of a certified nurse-midwife are covered if she or he is affiliated with or practicing in conjunction with a licensed facility and the services are provided under qualified medical direction.

13    Physical therapy is covered for inpatient physical therapy if it immediately follows a regular hospital admission. Physical therapy, physical medicine and rehabilitation services—or any combination of these—are covered as long as the treatment is prescribed by your doctor and designed to improve or restore physical functioning within a reasonable period of time. If you receive therapy on an inpatient basis, it must be short-term. Occupational, speech and post cochlear implant aural therapy are covered if prescribed by your doctor and provided by a licensed therapist (occupational, speech or post cochlear implant and aural, as applicable) in your home, in a therapist’s office or in an approved outpatient facility.

Up to 20 outpatient visits are covered per year for physical, occupational and speech therapy combined. You must receive any such services through a network provider in the home or office. Physical therapy provided in an outpatient department of a hospital is not covered The Plan will pay benefits for speech therapy only when the speech impediment or dysfunction results from injury, illness, stroke, cancer, autism spectrum disorders or a congenital anomaly, or is needed following the placement of a cochlear implant.

14   Durable medical equipment and supplies means buying, renting and/or repairing prosthetics (such as artificial limbs), and other durable medical equipment and supplies—but you generally must go in-network for them. In addition to the items listed above, the Plan covers:

• prosthetics and durable medical equipment from in-network suppliers, when prescribed by a doctor including:
  

– artificial arms, legs, eyes, ears, nose, larynx and external breast prostheses

– supportive devices essential to the use of an artificial limb

– corrective braces

– wheelchairs, hospital-type beds, oxygen equipment, sleep apnea monitors

– prosthetic shoe which replaces a partially or totally absent foot or is attached to a brace

– orthotics for foot care as deemed appropriate by the claims administrator will be limited as follows: up to one pair per covered adult (over age 17) per calendar year and up to two pairs per covered child (under age 17) per calendar year

– wigs for temporary loss of hair resulting from treatment of a malignancy or permanent loss of hair from an accidental injury

– replacement of covered medical equipment because of wear, damage, growth or change in patient’s need, when ordered by a doctor

– reasonable cost of repairs and maintenance for covered medical equipment.

You must pre-notify for the rental or purchase of durable medical equipment costing $1,000 or more. In addition, the Plan will cover the cost of buying equipment when the purchase price is expected to be less costly than long-term rental, or when the item is not available on a rental basis.

15    Cosmetic Surgery will not be a covered health service unless it is necessitated by injury, for breast reconstruction after cancer surgery, or is necessary to lessen a disfiguring disease or a deformity arising from or directly related to a congenital abnormality. These exceptions require pre-notification. Cosmetic Treatment includes any procedure that is directed at improving or changing the patient’s appearance and does not meaningfully promote proper function of the body or prevent or treat illness or disease.

16   Experimental or investigative means medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time UnitedHealthcare and the Fund make a determination regarding coverage in a particular case, are determined to be any of the following:

• not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use;

• subject to review and approval by any institutional review board for the proposed use (devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be Experimental or Investigational); or

• the subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 Clinical Trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

Exceptions:

• If you have a life threatening sickness or condition (one that is likely to cause death within one year of the request for treatment), UnitedHealthcare and the Fund may, at their discretion, consider an otherwise experimental or investigational service to be a covered health service for that sickness or condition. Prior to such consideration, UnitedHealthcare and the Fund must determine that, although unproven, the service has significant potential as an effective treatment for that sickness or condition, and that the service would be provided under standards equivalent to those defined by the National Institutes of Health.

Unproven services mean health services, including medications that are determined not to be effective for treatment of the medical condition and/ or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.

• Well-conducted randomized controlled trials are two or more treatments compared to each other, with the patient not being allowed to choose which treatment is received.
• Well-conducted cohort studies are studies in which patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group.

UnitedHealthcare has a process by which it compiles and reviews clinical evidence with respect to certain health services. From time to time, UnitedHealthcare issues medical and drug policies that describe the clinical evidence available with respect to specific health care services. These medical and drug policies are subject to change without prior notice. You can view these policies at www.myuhc.com.

Please note:

• If you have a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment), UnitedHealthcare and the Fund may, at their discretion, consider an otherwise unproven service to be a covered health service for that sickness or condition. Prior to such consideration, UnitedHealthcare and the Fund must first establish that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that sickness or condition, and that the service would be provided under standards equivalent to those defined by the National Institutes of Health.
• UnitedHealthcare and the Fund may, in their discretion, consider an otherwise unproven service to be a covered health service for a covered person with a sickness or injury that is not life-threatening. For that to occur, all of the following conditions must be met:

- If the service is one that requires review by the U.S. Food and Drug Administration (FDA) it must be FDA-approved.

- It must be performed by a physician and in a facility with demonstrated experience and expertise.

- The covered person must consent to the procedure acknowledging that UnitedHealthcare and the Fund do not believe that sufficient clinical evidence has been published in peer-reviewed medical literature to conclude that the service is safe and/or effective.

- At least two studies must be available in published peer-reviewed medical literature that would allow UnitedHealthcare and the Fund to conclude that the service is promising but unproven.

- The service must be available from a network physician and/or a network facility.

The decision about whether such a service can be deemed a covered health service is solely at UnitedHealthcare’s and the Fund’s discretion. Other apparently similar promising but unproven services may not qualify

17  Nutritional Counseling. The Plan will pay for covered health services for medical education services provided in a physician’s office by an appropriately licensed or healthcare professional when:

• education is required for a disease in which patient self-management is an important component of treatment; and
• there exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional.

Some examples of such medical conditions include:

• coronary artery disease;
• congestive heart failure;
• gout (a form of arthritis);
• renal failure;
• phenylketonuria (a genetic disorder diagnosed at infancy); and
• hyperlipidemia (excess of fatty substances in the blood).

Benefits are limited to three individual sessions per medical condition per calendar year.

18  Obesity Surgery. The Plan covers surgical treatment of morbid obesity provided all of the following are true:

• you have a minimum Body Mass Index (BMI) of 40, or 35 with at least 2 co-morbid conditions present;
• you are over the age of 21;
• you must use a United Resource Networks (U.R.N.) Bariatric Center of Excellence;
• you have completed a 6-month physician supervised weight loss program; and
• you have completed a pre-surgical psychological evaluation.

You will have access to a certain network of designated facilities and physicians participating in the Bariatric Resource Services (BRS) program known as a Bariatric Center of Excellence.

For obesity surgery services to be considered Covered Health Services under the BRS program, you must contact Bariatric Resource Services and speak with a nurse consultant prior to receiving services. You can contact Bariatric Resource Services by calling toll-free at 1-888-936-7246

All authorization information and enrollment for bariatric surgery must be initiated through United Resource Networks (U.R.N.). Covered participants seeking coverage for bariatric surgery should notify U.R.N. as soon as the possibility of a bariatric surgery procedure arises (and before the time a presurgical evaluation is performed) at a bariatric surgery center by calling U.R.N. at 1-888-936-7246 to enroll in the program.

Bariatric Resource Services (BRS) is a program administered by UnitedHealthcare or its affiliates made available to you by your Plan. The BRS program provides:

• Specialized clinical consulting services to members and eligible enrolled dependents to educate on obesity treatment options; and
• Access to specialized network facilities and physicians for obesity surgery services.

19   Accidental Dental Services are covered by the Plan when all of the following are true:

• treatment is necessary because of accidental damage;
• dental damage does not occur as a result of normal activities of daily living or extraordinary use of the teeth;
• dental services are received from a network participating Doctor of Dental Surgery or a Doctor of Medical Dentistry; and
• the dental damage is severe enough that initial contact with a physician or dentist occurs within 72 hours of the accident. (You may request an extension of this time period provided that you do so within 60 days of theinjury and if extenuating circumstances exist due to the severity of theinjury.)

The following services are also covered by the Plan

• dental services related to medical transplant procedures;
• initiation of immunosuppressives (medication used to reduce inflammation and suppress the immune system); and
• direct treatment of cancer or cleft palate.

Dental services for final treatment to repair the damage caused by accidental injury must be started within three months of the accident unless extenuating circumstances exist (such as prolonged hospitalization or the presence of fixation wires from fracture care) and completed within 12 months of the accident.

The Plan pays for treatment of accidental injury only for:

• emergency examination;
• necessary diagnostic x-rays;
• endodontic (root canal) treatment;
• temporary splinting of teeth;
• prefabricated post and core;
• simple minimal restorative procedures (fillings);
• extractions;
• post traumatic crowns if such are the only clinically acceptable treatment; and
• replacement of lost teeth due to injury. The lost tooth could be replaced by dentures or bridges depending on the nature of the injury.

20 Reconstructive procedures are services performed when the primary purpose of the procedure is either to treat a medical condition or to improve or restore physiologic function for an organ or body part. Reconstructive procedures include surgery or other procedures which are associated with an injury, sickness or congenital anomaly. The primary result of the procedure is not a changed or improved physical appearance.

Improving or restoring physiologic function means that the organ or body part is made to work better. An example of a reconstructive procedure is surgery on the inside of the nose so that a person’s breathing can be improved or restored.

Benefits for reconstructive procedures include breast reconstruction following a mastectomy and reconstruction of the non-affected breast to achieve symmetry. Replacement of an existing breast implant is covered by the Plan if the initial breast implant followed mastectomy. Other services required by the Women’s Health and Cancer Rights Act of 1998, including breast prostheses and treatment of complications, are provided in the same manner and at the same level as those for any other covered health service. You can contact UnitedHealthcare at the telephone number on your ID card for more information about benefits for mastectomy related services.

There may be times when the primary purpose of a procedure is to make a body part work better. However, in other situations, the purpose of the same procedure is to improve the appearance of a body part. Cosmetic procedures are excluded from coverage. Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic procedures. A good example is upper eyelid surgery. At times, this procedure will be done to improve vision, which is considered a reconstructive procedure. In other cases, improvement in appearance is the primary intended purpose, which is considered a cosmetic procedure. This Plan does not provide benefits for cosmetic procedures, as defined earlier in this section.

The fact that a covered person may suffer psychological consequences or socially avoidant behavior as a result of an injury, sickness or congenital anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure.

21  Transplant Services are inpatient facility services (including evaluation for transplant, organ procurement and donor searches) for transplantation procedures and must be ordered by a network provider and received at a designated facility. Benefits are available to the donor and the recipient when the recipient is covered under this Plan for any of the organ and tissue transplants listed below when the transplant meets the definition of a covered health service and is not experimental or investigational, or

• heart;
• heart/lung;
• lung;
• kidney;
• kidney/pancreas;
• liver;
• liver/kidney;
• liver/intestinal;
• pancreas;
• intestinal; and
• bone marrow (either from you or from a compatible donor) and peripheral stem cell transplants, with or without high dose chemotherapy. Not all bone marrow transplants meet the definition of a covered health service.

Benefits are also available for cornea transplants. A cornea transplant is not required to be performed at a designated facility; however, it must be performed at a UnitedHealthcare Network Facility in order to be considered a covered benefit.

Donor costs that are directly related to organ removal are covered health services for which benefits are payable through the organ recipient’s coverage under the Plan.

The Plan has specific guidelines regarding benefits for transplant services. Contact United Resource Networks at 1-888-936-7246 or Personal Health Support at the telephone number on your ID card for information about these guidelines.

22  The pre-planned home delivery of a child by a certified nurse-midwife is a covered service. The reimbursement rate for this service is at the contracted EP1 product United Healthcare obstetrician/gynecologist global rate.