Programs to Keep You Healthy Many health problems can be prevented by making positive changes to your lifestyle, including exercising regularly, eating a healthy diet, and not smoking. As a member, you can take advantage of our wellness programs at no additional cost. We offer wellness programs to our members from time to time. These programs include, but are not limited to: • online and in-person educational programs; • health assessments; • coaching; • biometric screenings, such as cholesterol or body mass index; • discounts We may provide incentives for you to participate in these programs. These incentives may include credits toward premium, and a reduction or waiver of deductible and/or copayments for certain covered healthcare services, as permitted by applicable state and federal law. For the subscriber of the plan, wellness incentives may also include rewards, which may take the form of cash or cash equivalents such as gift cards, discounts, and others. These rewards may be taxable income. Additional information is available on our website. Your participation in a wellness program may make your employer eligible for a group wellness incentive award. Your participation in our wellness programs is voluntary. We reserve the right to end wellness programs at any time. From time to time, we may offer you coupons, discounts, or other incentives as part of our member incentives program. These coupons, discounts and incentives are not benefits and do not change or affect your benefits under this plan. You must be a member to be eligible for member incentives. Restrictions may apply to these incentives, and we reserve the right to change or stop providing member incentives at any time. Care coordination gives you access to dedicated BCBSRI healthcare professionals, including nurses, dietitians, behavioral health providers, and community resources specialists. These care coordinators can help you set and meet your health goals. You can receive support for many health issues, including, but not limited to: • making the most of your physician’s visits; • navigating through the healthcare system; • managing medications or addressing side effects; • better understanding new or pre-existing medical conditions; • completing preventive screenings; • losing weight. Care Coordination is a personalized service that is part of your existing healthcare coverage and is available at no additional cost to you. For more information, please call (000) 000-XXXX (2273) or visit our website. If you have a chronic condition such as asthma, coronary heart disease, diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease, we’re here to help. Our tools and information can help you manage your condition and improve your health. You may also be eligible to receive help through our care coordination program. This voluntary program is available at no additional cost you. To learn more about disease management, please call (000) 000-0000 or 0-000-000-0000. Our entire contract with you consists of this agreement and our contract with your employer. Your ID card will identify you as a member when you receive the healthcare services covered under this agreement. By presenting your ID card to receive covered healthcare services, you are agreeing to abide by the rules and obligations of this agreement. Your eligibility for benefits is determined under the provisions of this agreement. Your right to appeal and take action is described in Appeals in Section 5. This agreement describes the benefits, exclusions, conditions and limitations provided under your plan. It shall be construed under and shall be governed by the applicable laws and regulations of the State of Rhode Island and federal law as amended from time to time. It replaces any agreement previously issued to you. If this agreement changes, an amendment or new agreement will be provided.
Home Health Care This plan covers the following home care services when provided by a certified home healthcare agency: • nursing services; • services of a home health aide; • visits from a social worker; • medical supplies; and • physical, occupational and speech therapy.
Behavioral Health Services Behavioral health services include the evaluation, management, and treatment for a mental health or substance use disorder condition. For the purpose of this plan, substance use disorder does not include addiction to or abuse of tobacco and/or caffeine. Mental health or substance use disorders are those that are listed in the most updated volume of either: • the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association; or • the International Classification of Disease Manual (ICD) published by the World Health Organization. This plan provides parity in benefits for behavioral healthcare services. Please see Section 10 for additional information regarding behavioral healthcare parity. This plan covers behavioral health services if you are inpatient at a general or specialty hospital. See Inpatient Services in Section 3 for additional information. This plan covers services at behavioral health residential treatment facilities, which provide: • clinical treatment; • medication evaluation management; and • 24-hour on site availability of health professional staff, as required by licensing regulations. This plan covers intermediate care services, which are facility-based programs that are: • more intensive than traditional outpatient services; • less intensive than 24-hour inpatient hospital or residential treatment facility services; and • used as a step down from a higher level of care; or • used a step-up from standard care level of care. Intermediate care services include the following: • Partial Hospital Program (PHP) – PHPs are structured and medically supervised day, evening, or nighttime treatment programs providing individualized treatment plans. A PHP typically runs for five hours a day, five days per week. • Intensive Outpatient Program (IOP) – An IOP provides substantial clinical support for patients who are either in transition from a higher level of care or at risk for admission to a higher level of care. An IOP typically runs for three hours per day, three days per week.
Health Plan An appropriately licensed entity that has entered into a contract with Subcontractor, either directly or indirectly, under which Subcontractor provides certain administrative services for Health Plan pursuant to the State Contract. For purposes of this Appendix, Health Plan refers to UnitedHealthcare Insurance Company.
Health Overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way;