UnitedHealthcare Insurance Company, Inc.

UnitedHealthcare Insurance Company, Inc.



Customer Service 877-835-9861

2021

UnitedHealthcare Advantage

The plan's health coverage qualifies as minimum essential coverage

and meets the minimum value standard for the benefits it provides. See

page 7 for details. This plan is accredited. See Page 11.

IMPORTANT

? Rates: Back Cover

? Changes for 2021: Page 13

? Summary of Benefits: Page 82

Enrollment in this plan is limited to the states of: Alabama, Arizona, Arkansas, California, Colorado,

Connecticut, Delaware, District of Columbia, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky,

Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska,

Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma,

Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia,

Washington, West Virginia, Wisconsin and Wyoming. You must live or work in our Geographic Service area to

enroll. See page 11 for requirements.

This is a new plan for 2020

Enrollment Codes for this Plan:

Y51 High Option - Self Only

Y53 High Option - Self Plus One

Y52 High Option - Self and Family

RI 73-903

Important Notice from UnitedHealthcare Insurance Company, Inc. About

Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the UnitedHealthcare Insurance Company Inc.'s

prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage

will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare

Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to

pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will

coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good

as Medicare¡¯s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every

month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug

coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay

this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the

next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare¡¯s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available.

Information regarding this program is available through the Social Security Administration (SSA) online at

, or call the SSA at 1-800-772-1213, TTY 1-800-325-0778.

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these

places:

? Visit for personalized help.

? Call 800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048).

Table of Contents

Introduction ...................................................................................................................................................................................3

Plain Language ..............................................................................................................................................................................3

Stop Health Care Fraud! ...............................................................................................................................................................3

Discrimination is Against the Law ................................................................................................................................................4

Preventing Medical Mistakes ........................................................................................................................................................5

FEHB Facts ...................................................................................................................................................................................7

Coverage information .........................................................................................................................................................7

No pre-existing condition limitation ...................................................................................................................................7

Minimum essential coverage (MEC) ..................................................................................................................................7

Minimum value standard ....................................................................................................................................................7

Where you can get information about enrolling in the FEHB Program .............................................................................7

Types of coverage available for you and your family .........................................................................................................7

Family Member Coverage ..................................................................................................................................................8

Children¡¯s Equity Act ..........................................................................................................................................................8

When benefits and premiums start ......................................................................................................................................9

When you retire ...................................................................................................................................................................9

When you lose benefits .......................................................................................................................................................9

When FEHB coverage ends ................................................................................................................................................9

Upon divorce .....................................................................................................................................................................10

Temporary Continuation of Coverage (TCC) ...................................................................................................................10

Converting to individual coverage ....................................................................................................................................10

Health Insurance Market Place .........................................................................................................................................10

Section 1. How This Plan Works .................................................................................................................................................11

General Features of our High Option Plan .......................................................................................................................11

How we pay providers ......................................................................................................................................................11

Your Rights and Responsibilities .....................................................................................................................................11

Your medical and claims records are confidential ............................................................................................................12

Service Area ......................................................................................................................................................................12

Section 2. We are a new plan ......................................................................................................................................................13

Section 3. How You Get Care .....................................................................................................................................................14

Identification cards ............................................................................................................................................................14

Where you get covered care ..............................................................................................................................................14

Plan providers .........................................................................................................................................................14

Plan facilities ...........................................................................................................................................................14

What you must do to get covered care ..............................................................................................................................14

Primary care ............................................................................................................................................................14

Specialty care ..........................................................................................................................................................14

Hospital care ...........................................................................................................................................................15

If you are hospitalized when your enrollment begins .......................................................................................................15

You need prior Plan approval for certain services ............................................................................................................15

Inpatient Hospital Admission ............................................................................................................................................15

Other Services ...................................................................................................................................................................15

How to request precertification for an admission or get prior authorization for Other services ......................................16

Non-urgent care claims .....................................................................................................................................................17

Urgent care claims ............................................................................................................................................................17

Concurrent care claims......................................................................................................................................................17

2021 UnitedHealthcare Insurance Company, Inc.

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Table of Contents

The Federal Flexible Spending Account Program ¨C FSAFEDS .......................................................................................17

Emergency inpatient admission ........................................................................................................................................18

Maternity Care ..................................................................................................................................................................18

If your treatment needs to be extended .............................................................................................................................18

What happens when you do not follow the precertification rules when using non-network facilities .............................18

Circumstances beyond our control ....................................................................................................................................18

If you disagree with our pre-service claim decision .........................................................................................................18

To reconsider a non-urgent care claim ..............................................................................................................................18

To reconsider an urgent care claim ...................................................................................................................................18

To file an appeal with OPM ..............................................................................................................................................19

Section 4. Your Costs for Covered Services ...............................................................................................................................20

Cost-Sharing......................................................................................................................................................................20

Copayments .......................................................................................................................................................................20

Deductible .........................................................................................................................................................................20

Coinsurance .......................................................................................................................................................................20

Your catastrophic protection out-of-pocket maximum .....................................................................................................20

Carryover ..........................................................................................................................................................................21

When Government facilities bill us ..................................................................................................................................21

Section 5. High Option Benefits Overview ................................................................................................................................24

Section 6. General Exclusions ¨C Services, Drugs and Supplies We Do not Cover .....................................................................65

Section 7. Filing a Claim for Covered Services .........................................................................................................................66

Section 8. The Disputed Claims Process.....................................................................................................................................68

Section 9. Coordinating Benefits with Medicare and Other Coverage .......................................................................................71

When you have other health coverage ..............................................................................................................................71

TRICARE and CHAMPVA ..............................................................................................................................................71

Workers¡¯ Compensation ....................................................................................................................................................71

Medicaid............................................................................................................................................................................71

When other Government agencies are responsible for your care .....................................................................................71

When others are responsible for injuries...........................................................................................................................71

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage .........................................72

Clinical trials .....................................................................................................................................................................72

When you have Medicare .................................................................................................................................................72

The Original Medicare Plan (Part A or Part B) .................................................................................................................72

Tell us about your Medicare Coverage ............................................................................................................................73

Medicare Advantage (Part C) ............................................................................................................................................73

Medicare prescription drug coverage (Part D) ..................................................................................................................75

Section 10. Definitions of Terms We Use in This Brochure .......................................................................................................77

Index............................................................................................................................................................................................80

Summary of Benefits for the High Option Plan of UnitedHealthcare Insurance Company - 2021 ............................................82

2021 Rate Information for UnitedHealthcare Insurance Company, Inc. ....................................................................................86

2021 UnitedHealthcare Insurance Company, Inc.

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Table of Contents

Introduction

This brochure describes the benefits of UnitedHealthcare Insurance Company, Inc. under contract (CS 2965) with the United States

Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may be reached at

1-877-835-9861 or through our website . The address for our administrative offices is:

UnitedHealthcare Insurance Company, Inc.

Federal Employees Health Benefits Plan

10175 Little Patuxent Parkway, 6th Floor

Columbia, MD 21044

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and

exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self

and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were

available before January 1, 2021, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually and changes are summarized on page 13. This is a new plan for January 1,

2021. Rates are shown at the end of this brochure.

Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples,

? Except for necessary technical terms, we use common words. For instance, ¡°you¡± means the enrollee and each covered family

member, ¡°we¡± means UnitedHealthcare Insurance Company, Inc.

? We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office

of Personnel Management. If we use others, we tell you what they mean first.

? Our brochure and other FEHB plans¡¯ brochures have the same format and similar descriptions to help you compare plans.

Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program premium.

Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency

that employs you or from which you retired.

Protect Yourself From Fraud - Here are some things that you can do to prevent fraud:

? Do not give your plan identification (ID) number over the phone or to people you do not know, except for your health care

providers, authorized health benefits plan, or OPM representative.

? Let only the appropriate medical professionals review your medical record or recommend services.

? Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

? Carefully review explanations of benefits (EOBs) statements that you receive from us.

? Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.

? Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.

? If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or

misrepresented any information, do the following:

- Call the provider and ask for an explanation. There may be an error.

2021 UnitedHealthcare Insurance Company, Inc.

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Introduction/Plain Language/Advisory

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