Provider Network
Q: Who are my participating providers?
Q: What is a primary care physician (PCP)? A: A primary care physician (PCP) is a doctor who manages your health care so you receive consistent medical care in an effective and efficient manner. Your PCP will coordinate your medical care through the use of participating specialty practitioners.
Q: Do I need to choose a PCP? A: Unity requires all members have a PCP. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. To select your PCP, Unity provides you with the following options:
Your PCP will manage your care and coordinate services through the participating specialty care practitioners. |
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Q: Can I change my PCP?
A: Yes. PCP changes are effective no later than the first day of the following month. Changes can be made by logging into MyChart, or by calling 800-548-6489.
Q: Do I need to see my PCP for all my health care?
A: You should talk with your PCP before seeing other types of practitioners so he/she may coordinate your health care.
Q: What if I need to see a specialist?
A: You should work with your PCP to determine the appropriate specialist. Unity does not require you to receive a referral prior to accessing in-network specialty care.
Q: Do I need Prior Authorization for certain services?
A: Yes. Specific types of services require Prior Authorization before the services are received. If Prior Authorization is not obtained, Unity will reduce the payment made for these covered services. View a list of services requiring Prior Authorization.
Q: Who files claims when I receive health care services?
A: When you receive care from participating practitioners, the practitioner will submit the claim for you. If you receive a bill from a participating practitioner prior to receiving your Explanation of Benefits, please send a message to Unity Customer Service through Ask an Expert within MyChart or call 800-362-3310.
Q: Who is covered as a dependent under my family plan?
A: Dependents include the subscriber’s legal spouse and eligible children. Eligible children are natural children, stepchildren, legally adopted children, or children for whom the subscriber or covered spouse has been appointed the legal guardian. A child is considered an eligible dependent if:
A grandchild is an eligible dependent as long as the parent is under the age of 18 and is an eligible dependent of the subscriber.
Q: Can I add dependents to my policy?
A: As a subscriber, you have the ability to request a dependent be added to your policy. When Unity receives the request, the dependent’s application may be subject to the health underwriting process. Unity will send a written notice regarding the acceptance or rejection of the application within 30 days of receiving it.
Q: Are behavioral (mental) health services covered under the Personal Options plan?
A: Personal Options does not currently offer a plan option with behavioral (mental) health coverage.
Q: What preventive care coverage do I have?
A: Preventive care services are covered by your plan without a copayment, coinsurance or deductible when received by a primary care provider. View a list of preventive care services.
Please note: This list is a summary and is subject to change based on federal regulations.
Q: Are maternity services covered under Personal Options?
A: Personal Options does not currently offer a plan option with maternity services.
Q: What is the overall maximum dollar benefit of the plan?
A: There is no lifetime benefit maximum per member. There is an annual maximum benefit for essential benefits and there are maximum benefits for certain services such as (but not limited to):
For your specific dollar benefit information, please refer to your Schedule of Benefits.
Q: What are essential benefits?
A: Essential benefits are items or services covered under the Affordable Care Act that fall into these general categories:
Please Note: This list is a summary and is subject to change based on federal regulations.
Q: What is considered an emergency or urgent care situation?
A: Emergency care is required when the onset of a sudden or acute illness, accident or injury with symptoms of sufficient severity, including severe pain, would lead a prudent layperson to reasonably conclude that a lack of immediate medical attention will likely result in serious jeopardy to:
Urgent care services are those needed due to illness or symptoms where delay in care could jeopardize your health or result in disability.
Q: What should I do if I need emergency or urgent care?
A: If it is an emergency condition, get help first. These services are covered, subject to the plan copayment, deductible or coinsurance, when provided at the nearest emergency room. Urgent care services are covered less any copayment, deductible or coinsurance when provided by an urgent care facility. In addition, you will be responsible for charges above usual, customary and reasonable (UCR) if you receive care from an out-of-plan provider. You must call Unity at 800-362-3310, Monday through Friday, within 72 hours after receiving urgent care or emergency treatment from a non-participating provider. Failure to meet these requirements within the proper time frame will result in a monetary penalty that does not apply to any deductible, coinsurance or out-of-pocket maximum.
If you receive covered services from an out-of-plan provider, you are responsible for submitting a claim form or an itemized statement of services received. You must submit the claims to Unity Health Insurance within 90 days from the date the services were provided.
Q: What are the charges I can expect if I use an emergency room or urgent care facility?
A: You can usually expect to receive anywhere from one to three but sometimes more claims per visit depending on the services provided during your visit. The charges you can expect include but are not limited to:
Q: What is a copayment?
A: A copayment is the dollar amount you are responsible for paying the provider for a service. Based on the service, you pay only the dollar amount shown on your plan's Schedule of Benefits. To view your Schedule of Benefits, login to MyChart.
Q: What is coinsurance?
A: Coinsurance is the term used to identify the percentage of health care costs you are responsible for paying the provider. You pay the percentage listed on your Schedule of Benefits.
Q: What is a deductible?
A: A deductible is the amount you are required to pay for certain covered medical services before Unity will make a payment. Your deductible is listed on your Schedule of Benefits. Once the deductible is met, you pay a percentage of the cost of the covered medical services. See your Schedule of Benefits for specific details on your chosen plan design.
Q: What is my annual out-of-pocket limit?
A: Your annual out-of-pocket limit is specified in your Schedule of Benefits. Copayments do not apply to your annual out-of-pocket limit, nor do they apply to deductibles. Amounts exceeding usual, customary and reasonable (UCR) charges do not apply to the annual out-of-pocket limit. See your Schedule of Benefits for specific details on your chosen plan design.
Q: What is UCR?
A: UCR is the allowable dollar amount for the same or similar services and supplies provided by health care providers within a geographic area. UCR applies only to services received from an out-of-network provider. Any amount exceeding the maximum allowable fee does not apply to the annual out-of-pocket limit.
Q: How does a deductible plan work?
A: Before Unity will make a payment toward any services you receive, you must first pay the deductible found on your Schedule of Benefits. After the deductible is met, Unity will pay its percentage of the coinsurance until you have met the dollar amount listed as the annual out-of-pocket limit.
Q: How are the rates determined for Personal Options?
A: The benefits are calculated on a plan year basis. Unity has two anniversary dates associated with this plan—January 1 and July 1.
Your initial premium will be valid until December, 2013 (unless you change age brackets or coverage during this time). Thereafter, your premium may increase on an annual basis on your anniversary date unless we notify you it will increase more frequently. You will be notified of a rate increase at least 30 days in advance of the increase.
Please Note: A $10.00 monthly charge will be applied to your premium if you wish to receive your invoices via mail. To avoid this charge, you will need to sign up for electronic premium invoices within MyChart once your coverage is effective.
Q: If I apply for Personal Options, can my application be denied?
A: Yes. Unlike a group policy, Unity may decline Personal Options applications. Unity puts all Personal Options applications through the health underwriting process.
Q: How long does it take to underwrite an application?
A: Unity will make a decision within 10 business days from receipt of a completed application. To be complete, Unity must receive:
Q: What is the effective date of my policy?
A: If your application is approved by Unity, you will receive a letter informing you of your approval and your effective date. The effective date will always be the 1st of the month.
Q: Can someone under age 18 apply for a Personal Options policy?
A: No. The policyholder must be age 18 or older. Dependents under age 18 may be covered under the subscriber’s policy but may not have policies in their names.
Q: Who is the subscriber?
A: If you are applying for family coverage, Unity considers the oldest family member to be the subscriber on the policy. All other members are dependents.
Q: Can my spouse and I apply for separate policies?
A: Yes.
Q: I notice Personal Options has tobacco and non-tobacco user rates. How are rates determined if only one member of the family applying for coverage is a tobacco user?
A: Tobacco use affects all members of the family. The entire family is subject to the tobacco user rates.
Q: What is quality improvement and does Unity have a quality improvement program?
A: Quality Improvement (also called Quality Assurance) is a process designed to measure and track the continuous improvement of care and services offered to Unity members. Unity’s Quality Improvement processes identify opportunities to improve care and service, identify actual or potential problems, and identify trends which suggest variation in the outcome of care and service received.
The scope of Unity’s Quality Improvement Program includes preventive, acute and chronic care services; services received in inpatient and outpatient settings; and PCPs, specialists, and ancillary practitioners involved in delivering care to you and your family. You can obtain more information on Unity’s Quality Improvement Program by calling Unity’s Health Services Department at 866-884-4601.
Q: Does Unity have a prescription drug formulary?
A: Yes. View a copy of Unity’s Prescription Drug Formulary. Unity does not cover all prescription drugs. In addition, some drugs may require Prior Authorization. In either situation, the ordering physician must submit a request for the drug and a pharmacist within Unity’s pharmacy program will make a coverage decision. A member can also begin this request process or check on the status of a request by calling Unity Pharmacy Services at 800-788-2949.
Personal Options has an optional three-tier prescription drug rider available for purchase. The three-tier prescription drug rider provides coverage for prescription drugs prescribed by a practitioner and received from a participating pharmacy. The prescription drug rider has three copayment levels— $10 for generic, $25 for brand, and $50 for non-formulary. There is also a $100 copayment for specialty pharmaceutical medications. Please see Unity’s Prescription Drug Formulary for more details. Some medications may require Prior Authorization.
