List of Preventive Care Services and the Summary Plan Description

Posted Sat December 9, 2006 11:23 pm, by Sharad A. written to United HealthCare

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I have enrolled in United HealthCare's High Deductible plan for the year 2006. I am an employee of Fidelity Investments. In making a decision to enrol in the same plan for 2007, I had a few questions about what is considered 'Preventive Care'. This is what the published FAQ stated in the matter:

"Q. What is considered preventive?
A. You pay $20 for preventive care services The HealthFlex High-Deductible Plan covers a wide range of preventive care services after you pay a $20 copay when you use network providers. The low copay is designed to ensure the high deductible does not discourage you from getting important preventive services.

Examples of preventive care services:

age-appropriate routine screenings, such as:
blood pressure
cholesterol
vision
hearing
diabetes
pap smear
mammogram
colonoscopy
bone density
annual office visits and exams
well-child care
lab tests and x-rays
immunizations
prenatal visits and screenings

It is important to note that preventive care services are covered at 100%, after a $20 copay, only when performed for preventive reasons. Any services provided as part of a diagnostic or treatment plan are subject to the deductible and coinsurance.

For a complete list of preventive care services, please call UnitedHealthcare at 877-240-4016."

Per the last statement in the FAQ, I called UHC at the 877 number provided and asked for the complete list of preventive care services. I called on 11/07/06 and talked to Alba B (reference #B6311122558324). She was unable to give me a list as required. She stated that she would make inquiries and get back to me within 10 days.

I called back on 11/16/06 and talked to James. James continued to state that if I gave him a procedure code he could tell me whether it is covered or not. I tried to explain to him that I did not have a specific procedure code but that I wanted the complete list as specified in the FAQ. I read out the FAQ comment to him:
"For a complete list of preventive care services, please call UnitedHealthcare at 877-240-4016."

He was unable to fathom the simple meaning of this simple sentence. I also referred him to Notice 2004-23 published by IRS. This notice has a list of Safe Harbor Preventive Care Services. I asked the agent if he would be kind enough to give me the list of services that UHC convers under the Safe Harbor.

I have not yet received the list and am at my wits end as to what I can do to obtain the same.

I would like two things:

1. Complete List of Preventive Care Services
============================================
The FAQ published by UHC in regards to the High Deductible Plan states:
"For a complete list of preventive care services, please call UnitedHealthcare at 877-240-4016."

I would like the complete list. I do not want the list in the FAQ:
"
age-appropriate routine screenings, such as:
blood pressure
cholesterol
vision
hearing
diabetes
pap smear
mammogram
colonoscopy
bone density
annual office visits and exams
well-child care
lab tests and x-rays
immunizations
prenatal visits and screenings
"

The 'such as' in this list bothers me. I want the complete list as stated in the FAQ. The list in Notice 2004-23 is far more specific than this FAQ. Is everything in that notice covered?

2. Summary Plan Description
===========================
I tried to get this information from UHC's website. The website does not have this information and states:
"PLEASE NOTE: This section includes general information about your medical benefit plan. This is not the legal summary plan description (SPD) of the plan or a document under which the plan is maintained. For all final terms and conditions of your plan, please refer to your written SPD. Information on this Web site does not override your written SPD. Any discrepancies between this information and your written SPD will be governed by the written SPD. Employees and other plan participants should refer to their SPD in order to determine whether any information, other than that referenced in this site, is applicable to their situation. The benefits described on this Web site are subject to change at any time."

I have tried to get the SPD as well, but the agents have been unable to help me.

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Re: List of Preventive Care Services and the Summary Plan Description by S. Brown Posted Mon December 11, 2006 @ 8:53 PM First of all, you need to obtain the SPD from your employer. Second, it is important to understand how a high deductible plan works. I have read the information link you provided to another poster and here's how I'm understanding this situation. There are specific, basic diagnostic tests that will be performed for a flat fee - - in your case $20.00 - - and not require you to meet the high deductible you agreed to. However, the $20.00 only covers the actual tests - - any treatment involved will be subject to your deductible. I agree that it shouldn't be this difficult to get the list from UHC and if I were you I would contact my employer with my concerns. Finally, it sounds to me like you are attempting to determine if a specific "item" is covered under the $20.00 co-pay without your meeting the deductible. If this is the case, then I would simply come out and ask the question and then proceed to obtain a complete list. Good luck. Reply Secretive Business Models by Sharad Thu December 14, 2006 @ 7:55 AM I don't get it . . . . by S. Brown Fri December 15, 2006 @ 5:24 PM Thanks ... by Sharad Sat December 16, 2006 @ 5:52 PM Re: List of Preventive Care Services and the Summary Plan Description by Sharad Posted Sun December 10, 2006 @ 11:20 AM Hi customerssuck (interesting bias you have), I agree with you that probably the SPD needs to be procured from the employer. I wasn't sure if UHC provided a separate SPD with more details. The one from the employer does not have the details I seek. But that is not my main complaint. Can you explain to me what the following sentence means in English?: "For a complete list of preventive care services, please call UnitedHealthcare at 877-240-4016." To me it means that if I call the 877 number, they will send me a complete list of preventive care services. Which, obviously, they are unwilling to provide. Also take a look at Notice 2004-23: http://www.ustreas.gov/press/releases/reports/notice200423.pdf Look at the appendix. Do you see what I am talking about? It is a comprehensive list published by the United States Department of Treasury on what "can" be considered preventive by a HDHP. Which of those a plan does or does not cover, we need to find out from the plan sponsor. Hope this clarifies the issue better. Thanks, Sharad Reply Re: List of Preventive Care Services and the Summary Plan Description by customerssuck Posted Sun December 10, 2006 @ 10:41 AM You will not be able to get a copy of the SPD from United, you have to get that from your employer. Secondly, it states they may be covered because not all of those services are appropriate for all age groups. For example, a colonoscopy is not considered routine preventive care until after the age of 50. You can certainly have one but it's not going to be considered routine preventive care until after you turn 50. Reply