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© 2024 United HealthCare Services, Inc. All Rights Reserved.Get to Know Your BenefitsSchool District of Tigerton 2024-2025 Plan Year146904
© 2020 United HealthCare Services, Inc. All rights reserved.Plan Overview 2024-20252Key Items to Understand from our time today:- No Doctor and Copay Changes- Prescription Rx plan is staying the same- Provider Network is Unchanged (once again there is no out of network providers)- Technology- www.myuhc.com- UHC App for your Smartphone- United Healthcare Healthy Initiatives- Tom Madden, iPlanRx - www.iplanrx.com - Contact info: tom.madden@iplanrx.com / 920-221-1633
© 2024 United HealthCare Services, Inc. All Rights Reserved.UnitedHealthcare Choice plan3Highlights of the UnitedHealthcare Choice plan:• Both network and out-of-network services are covered• A primary care provider (PCP) is optional• No referrals are needed to see a specialist• Preventive care is covered at 100%**By most plans in our network Please read your plan documents. Additional information such as benefit details, plan limitations and exclusions, and the costs of coverage can be found in the Summary of Benefits.Certain preventive care items and services, including immunizations, are provided as specified by applicable law, including the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services may be based on your age and other health factors. Other routine services may be covered under your plan, and some plans may require copayments, coinsurance or deductibles for these benefits. Always review your benefit plan documents to determine your specific coverage details.UnitedHealthcare Insurance CompanyNetwork care costsCopayPCP No copaySpecialist $100DeductibleIndividual $3,000Family $6,000Coinsurance 50%Out-of-pocket limitIndividual $7,350Family $14,700There is no coverage for out-of-network carePlease read your plan documents for more information.EI20443298.2
Unlimited$2,000 Ded.100% Coverage Preventative CareEmployee share of 100% would total $3,000 for Single and $6,000.00 for Single + DependentsKey Points of the EBS Bridge 2024-25 Plan:- You will pay the first $2,000 of your deductible. The EBS Plan will pay the $1000.00 after. -Then your coinsurance is paid 100% until $7,700 has been incurred. You pay the next $1,000.00 after $7,700 has been reached. -Your total deductible and coinsurance out of pocket for the year is $3,000.00 -This does not include your $1,000.00 HRA amount which would lower your out of pocket even further-Copays are not eligible to be paid by your EBS policy. 50%/50%Yellow Shaded Areas = Employee Responsibility100%Single $1,000.00 paid by EBS Family $2,000.00 paid by EBS$1,000United Healthcare Broad Provider Network:Aspirus, Aurora, Bellin, Thedacare, Prevea, Marshfield, Children’s Hospital, Froedtert, UW HealthDon’t Forget about your HRA
Unlimited$1,000 Ded.100% Coverage Preventative CareEmployee share of 100% would total $2,000 for Single and $4,000.00 for Single + DependentsKey Points of the EBS Bridge 2024-25 Plan:- You will pay the first $2,000 of your deductible. The EBS Plan will pay the $1000.00 after. -Then your coinsurance is paid 100% until $7,700 has been incurred. You pay the next $1,000.00 after $7,700 has been reached. -Your total deductible and coinsurance out of pocket for the year is $3,000.00 -This does not include your $1,000.00 HRA amount which would lower your out of pocket even further-Copays are not eligible to be paid by your EBS policy. 50%/50%Yellow Shaded Areas = Employee Responsibility100%Single $1,000.00 paid by EBS Family $2,000.00 paid by EBS$1,000United Healthcare Broad Provider Network:Aspirus, Aurora, Bellin, Thedacare, Prevea, Marshfield, Children’s Hospital, Froedtert, UW Health$1,000 HRA from EBC
Present your insurance cardStep 1When receiving a service, you present your insurance carrier card to your health care provider. Your health care provider submits the expense to your insurance carrier.You receive an EOB.Step 2Your insurance carrier reviews the expense, negotiates charges, awards discounts, and creates an Explanationof Benefits (EOB), which is sent to you and your health care provider.How to Use your HRAYour HRA (Health Reimbursement Arrangement) is an IRS-approved health care benefit plan that allows your employer to reimburse you for your eligible expenses, helping to soften the financial impact of today’s commonly high out-of-pocket expenses. Your reimbursements from an HRA are tax-free.© Employee Benefits Corporaon ID P3-4011 0424Contact Uswww.ebcflex.com(800) 346-2126participantservices@ebcflex.com|My Company Plan, which you will receive with your Summary Plan Description (SPD), details the expenses that can be reimbursed through your HRA.If your HRA reimburses out-of-pocket medical expenses such as deductible, coinsurance, or copays, follow the steps below to submit your claims and get reimbursed through your HRA.If your HRA reimburses other expenses that would not be eligible under your medical insurance, please follow the stepson the Submitting Claims flyer that is available on your participant online account.You submit a claim with each EOB.Step 3Submit a claim online or through the EBC Mobile app and attach each EOB. On the claim, enter the full amount shown on your Explanation of Benefits (EOB) [A], the type of service (deductible, coinsurance, medical copay, or prescription), and the date of service. We will automatically make any calculations necessary in accordance with your plan design.We reimburse you.Step 4If your claim qualifies as an eligible expense under your company’s HRA plan design, we issue yourreimbursement check according to the terms of your HRA. Use this reimbursement to pay the bill from your health care provider. (Direct deposit is also available.)Date ofServiceTotalChargesAmountAllowedNon-coveredChargesDeductibleCoinsuranceCopayTotal PatientResponsibility01/17/2014$1,000.00$1,000.00--$495.38$504.62$0.00$1,000.0002/09/2014$365.98$365.98--$0.00$365.98$0.00$365.9803/01/2014$154.62$154.62--$104.62$0.00$50.00$154.62Example EOB:Example Claim:Date ofServiceType of ServiceAmount01/17/2014Deductible$495.3801/17/2014Coinsurance$504.6202/09/2014Coinsurance$365.9803/01/2014Deductible$104.6203/01/2014Copay$50.00
Submitting Claims Online 1. Visit www.ebcflex.com and log in as a participant. 2. Select Submit a New Claim [A] in the menu and enter your claim information. 3. Attach the required documentation to your claim. 4. Review and submit your claim information and documentation.Submitting ClaimsSubmitting Claims with EBC Mobile 1. Login to your EBC Mobile account. If you don’t have the EBC Mobile app, you can download it from the App Store or Google Play. 2. Select Submit a Claim [B] at the bottom of your screen and enter your claim information. 3. Attach the required documentation to your claim. 4. Review and submit your claim information and documentation.Any device, any time.Submitting your claims online or through the EBC Mobile app helps you better manage your claims at home or on the go. If you don’t have an account set up, you can create your account online or on EBC Mobile by selecting Register on the login screen. B© Employee Benefits Corporation ID P1-104 0423 A
Claim FormSubmit Your ClaimOnline: Logintoyouronlineaccountatwww.ebcex.comandclickSubmit Claim.Fax: Faxcompletedclaimformandrequireddocumentaon(608)831-4790.© Employee Benefits Corporation ID P1-9069 10231SupportPhone: (800) 346-2126 | (608) 831-8445Email: parcipantservices@ebcex.comHow to Complete the Claim Form1. Complete the Account Holder Information section in full. Be sure to include the last 4 digits of your Social Security or Identification Number and your email address.2. Review the Benefit Codes. A. Enter the Benefit Code for your claim: [F] Health Care FSA (BESTflex Plan FSA that reimburses medical, dental and vision expenses) [L] Limited Health Care FSA (BESTflex Plan FSA that reimburses dental and vision expenses) [D] Dependent Care FSA (BESTflex Plan FSA that reimburses daycare expenses) [I] Individual Billed Insurance Premiums (BESTflex Plan account that reimburses insurance premiums) [H] HRA (EBC HRA reimbursement) [HF] Product Linking (Allows expense to be reimbursed out of the EBC HRA first, then the BESTflex Plan Health Care FSA/Limited Health Care FSA. If your EBC HRA allows rollover, this feature is not available. If the expense is not eligible in one of your plans, the whole amount will be processed from the eligible plan. [DC] Debit Card Substantiation [O] Offset Claim for an outstanding debit card purchase [LS] Lifestyle Spending Account (LSA) Be sure to include a “Benefit Code” for each claim; your claim cannot be processed without it.3. Complete the Claims Section. Information required in order to process the claim: • Date of Service - both start and end date • Dollar amount for each line • Name of provider • Description of Service • Total dollar amount for the entire page4. If applicable, obtain the Service Provider Signature for Dependent Care and Lifestyle Spending Account (LSA) expenses.How to Submit the Claim FormOnline (fastest)1. Log into your online account at www.ebcflex.com.2. After you log in, click Submit a New Claim under Quick Links.3. Complete the online form, upload required documentation and submit.FaxFax the completed claim form and required documentation to (608) 831-4790.Setup Direct DepositGet your money faster and have your reimbursement funds deposited electronically and securely in your checking or savings account. 1. Log in to your online account at www.ebcflex.com. 2. After you log in, open the main menu. 3. Find the Manage section and click Direct Deposit.You may also download the Direct Deposit Form at www.ebcflex.com/forms. Simply complete the form and submit it with your Claim Form.Important information you need when submitting claims to Employee Benefits Corporation• If we have your email address on file, we will email you when your claim is processed. Please allow 2 business days from our receipt of your Claim Form before viewing the status of your online account in My Account Assistant (log in at www.ebcflex.com).• Remember to send appropriate claim documentation with your form that verifies the expenses you are submitting for reimbursement. Claim documentation needs to include the Provider Name, the Date(s) of Service, a Description of the Expenses incurred and the Expense Amount. Cancelled checks and non-itemized credit card receipts are not valid forms of documentation.• Retain original copies of the Claim Form and expense documentation for your files; Claim Forms, receipts and claims information will not be returned.• If you request that we reissue a claim reimbursement to you for any reason, there is a $25 stop payment fee.Lifestyle Spending Account Expenses• Refer to the Plan Overview Document to review your plan’s eligible expenses. Medical expenses are not eligible.• For Lifestyle Spending Account (LSA) expenses a service provider signature is required when an itemized receipt is not available for the service rendered.• Refer to the Plan Overview Document for the length of your runout period, which determines the number of days you have after the plan year ends to submit claims.BESTflex Plan FSA and EBC HRA Expenses• When submitting claims for BESTflex Plan FSA expenses, similar services can be combined on a single line by using a range of dates. For example, you could use a single claim entry for a month of prescription expenses by completing the Claim Form as follows: Service Start Date: 01/01/2017, Service End Date: 01/31/2017, Description of Service: Prescription Co-pays.• If you swiped your Benefits Card for an ineligible expense or do not have the supporting documentation, you can offset the charge by submitting documentation for another FSA eligible expense that was not paid for with your Benefits Card and has not already been submitted for reimbursement. You can submit the offsetting claim by completing a claim form and typing “O” in the Benefit Code box, write in the Claim ID for the Benefits Card transaction you want to offset on the Description of Service line of the claim form, and attach a copy of the offsetting claim documentation.• When submitting claims for EBC HRA expenses: claim the full eligible amount shown on your Explanation of Benefits (EOB) or receipt. We will automatically make any calculations necessary in accordance with your plan design.• Refer to My Company Plan or your Summary Plan Description for the length of your runout period, which determines the number of days you have after the plan year ends to submit claims.
Claim FormSubmit Your ClaimOnline: Logintoyouronlineaccountatwww.ebcex.comandclickSubmit Claim.Fax: Faxcompletedclaimformandrequireddocumentaon(608)831-4790.© Employee Benefits Corporation ID P1-9069 10232SupportPhone: (800) 346-2126 | (608) 831-8445Email: parcipantservices@ebcex.comAccount Holder Informaon Last 4 Digits of Social Security or Identification NumberTo ensure mely and accurate claims processing, please complete the enre form. (Required)First Name Last NameEmail Address (we do not share your email address) EmployerClaimsBenefit Codes:F Health Care FSA L Limited Health Care FSA D Dependent Care FSA I Indv Billed Ins Premiums H HRA HF HRA rst, then FSADC Debit Card Substanaon O Oset Claim for an outstanding debit card purchase LS Lifestyle Spending Account (LSA)Enter one Benet Code per claim line below.Service Start Date (mm-dd-yyyy) Descripon of ServiceBenet Code Service End Dates (mm-dd-yyyy) Provider Person Receiving Service (Required for HRA)$Service Provider Signature (Dependent Care FSA and Lifestyle Spending Account (LSA) Only) Claim AmountService Start Date (mm-dd-yyyy) Descripon of ServiceBenet Code Service End Dates (mm-dd-yyyy) Provider Person Receiving Service (HRA Only)$Service Provider Signature (Dependent Care FSA and Lifestyle Spending Account (LSA) Only) Claim AmountService Start Date (mm-dd-yyyy) Descripon of ServiceBenet Code Service End Dates (mm-dd-yyyy) Provider Person Receiving Service (HRA Only)$Service Provider Signature (Dependent Care FSA and Lifestyle Spending Account (LSA) Only) Claim AmountService Start Date (mm-dd-yyyy) Descripon of ServiceBenet Code Service End Dates (mm-dd-yyyy) Provider Person Receiving Service (HRA Only)$Service Provider Signature (Dependent Care FSA and Lifestyle Spending Account (LSA) Only) Claim AmountClaim Total:$Claim AuthorizaonBy submitting this form, I understand, agree to, and certify the following statements. This Claim Form is complete and correct. I am claiming reimbursement only for eligible expenses incurred during the applicable plan year by eligible plan participants. These expenses have not been and will not be reimbursed by any other benefit plan or person, or claimed as an income tax deduction. These expenses are legal under state and federal law. Additional information may be requested from me in order to adjudicate my claim appropriately. I consent to the use and disclosure of my information in accordance with Employee Benefits Corporation’s online privacy policy and applicable law solely for the purposes of administering my benefits as outlined in the agreement between my employer and Employee Benefits Corporation. If I am submitting a Lifestyle Spending Account claim, I certify the expenses listed above are not medical expenses and I understand reimbursements are in the form of taxable benefits.By submitting this form I certify the above.
© 2024 United HealthCare Services, Inc. All Rights Reserved.Prioritizing care that helps you stay healthy6For more information, check your plan documents. Certain preventive care items and services, including immunizations, are provided as specified by applicable law, including the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services may be based on your age and other health factors. Other routine services may be covered under your plan, and some plans may require copayments, coinsurance or deductibles for these benefits. Always review your benefit plan documents to determine your specific coverage details.Preventive care — like checkups, screenings and immunizations — is 100% covered by most of our plans when you stay in the network. A preventive care visit may be a good time to:• Build a relationship with your primary care provider (PCP)• Find guidance for future medical needs• Check up on your health when you’re symptom-free EI20409450.2
© 2024 United HealthCare Services, Inc. All Rights Reserved.24/7 Virtual Visits7Quality care from anywhereChoosing to see a provider by phone or video* may save you the time and cost** of a visit to the emergency room or urgent care. Get virtual help for common concerns like:• Cough• Headache• Sore throat• Prescription needs****Data rates may apply. **The Designated Virtual Visit Provider's reduced rate for a 24/7 Virtual Visit is subject to change. ***Certain prescriptions may not be available and other restrictions may apply.24/7 Virtual Visits is a service available with a Designated Virtual Network Provider via video, or audio-only where permitted under state law. Unless otherwise required, benefits are available only when services are delivered through a Designated Virtual Network Provider. 24/7 Virtual Visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times, or in all locations, or for all members. Check your benefit plan to determine if these services are available. EI20445653.2
© 2024 United HealthCare Services, Inc. All Rights Reserved.Designated Diagnostic Provider (DDP)See providers in your network by visiting myuhc.com Please read your plan documents. Additional information such as benefit details, plan limitations and exclusions, and the costs of coverage can be found in the Summary of Benefits.Select a Designated Diagnostic Provider (DDP) for outpatient laboratory and imaging services that will likely save you money.Non-DDP laboratory and imaging services will cost you moreLet your primary care provider know that a DDP facility is the lowest cost for you. Look for the green check to confirm DDP status EI20443299.1Find a DPP at myuhc.com® > Find Care & Costs or on the UnitedHealthcare® app
© 2024 United HealthCare Services, Inc. All Rights Reserved.Finding a network provider, before you seek care9To check if the providers you see now are included in your plan:4Select Choice and add your location12Go to uhc.com/providersearchChoose Medical Directory3Choose Employer and Individual Plans EI221836753.2
© 2024 United HealthCare Services, Inc. All Rights Reserved.10$0 costs on insulin and other vital prescription drugsIf you are not currently enrolled with UnitedHealthcare pharmacy benefit coverage, you may access your health plan’s member website for additional information during your open enrollment period or you may contact your employer or health plan for additional information. Medications are categorized by common therapeutic conditions in this reference guide for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines how these medications may be covered for you. Where differences are noted between this reference guide and your benefit plan documents, the benefit plan documents will govern. This document applies to commercial group members of UnitedHealthcare plans.The UnitedHealthcare Vital Medication Program offers these select prescription drugs at no out-of-pocket cost to you:• Insulin – Rapid, short and long-acting • Epinephrine – Allergic reactions • Glucagon – Hypoglycemia (low blood sugar) • Naloxone – Opioid overuse • Albuterol inhaler – AsthmaOptum Rx® is an affiliate of United HealthCare Insurance CompanyEI20445652.2$0out-of-pocketcost
© 2024 United HealthCare Services, Inc. All Rights Reserved.Discover the advantages of home delivery11Get no-cost standard shippingReceive a 3-month supply of a maintenance medicationSave onmedication costsSet up refill reminders EI20445652.3Access a pharmacist 24/7 for questions about medicationsOptum Rx® is an affiliate of United HealthCare Insurance Company
© 2024 United HealthCare Services, Inc. All Rights Reserved.Two convenient ways to access your plan12With myuhc.com®, you can:• Find and estimate costs• Search network providers• Check on claims and plan balancesOn the UnitedHealthcare® app, also: • Video chat with a provider 24/7• Access your health plan ID cardMembers can access a cost estimate online or on the mobile app. None of the cost estimates are intended to be a guarantee of your costs or benefits. Your actual costs may vary. When accessing a cost estimate, please refer to the website or mobile application terms of use under Find Care & Costs section. The UnitedHealthcare® app is available for download for iPhone® or Android®. iPhone is a registered trademark of Apple, Inc. Android is a registered trademark of Google LLC.Download the app EI232260752.2
© 2024 United HealthCare Services, Inc. All Rights Reserved.Behavioral Health Solutions13Support for your emotional well-being•Depression, stress and anxiety•Relationship difficulties•Coping with grief and loss•Meditation, mindfulness and stress relief•Compulsive habits and eating disorders•Alcohol and drug use recovery•Medication management•Legal or financial concernsEI20445653.2
© 2024 United HealthCare Services, Inc. All Rights Reserved.Resources for your precious deliveryLearn what to expect when a little one’s on the way, including:• Trimester benchmarks• Nutrition and exercise• Breastfeeding and postpartum careMaternity Support14The information provided under Maternity Support is for general informational purposes only and is not intended to be nor should be construed as medical and/or nutritional advice. UnitedHealthcare makes no representation or warrant with regard to the accuracy of the information presented. If you believe that you may have any emergency medical condition you should immediately call 9-1-1. Participants should consult an appropriate health care professional to determine what may be right for them. If you have questions about the information presented or questions about health care services, supplies, or treatments, you should consult your health care provider before making any health care decisions. Employers are responsible for ensuring that any wellness programs they offer to their employees comply with applicable state and/or federal law, including, but not limited to, GINA, ADA and HIPAA wellness regulations, which in many circumstances contain maximum incentive threshold limits for all wellness programs combined that are generally limited to 30% of the cost of self-only coverage of the lowest-cost plan, as well as obligations for employers to provide certain notices to their employees. Employers should discuss these issues with their own legal counsel.EI20445653.2
© 2024 United HealthCare Services, Inc. All Rights Reserved.UnitedHealthcare Rewards15Dollars earned your wayGet rewarded for a variety of actions, like: • Completing a health survey• Getting an annual checkup• Tracking your fitness and sleep Reach program goals and you could earn up to $300.UnitedHealthcare Rewards is a voluntary program. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice. You should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for you. Receiving an activity tracker, certain credits and/or rewards and/or purchasing an activity tracker with earnings may have tax implications. You should consult with an appropriate tax professional to determine if you have any tax obligations under this program, as applicable. If any fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated from the program. If you are unable to meet a standard related to health factor to receive a reward under this program, you might qualify for an opportunity to receive the reward by different means. You may call us toll-free at 1-866-230-2505 or at the number on your health plan ID card, and we will work with you (and, if necessary, your doctor) to find another way for you to earn the same reward. Rewards may be limited due to incentive limits under applicable law. Components subject to change. This program is not available for fully insured members in Hawaii, Vermont and Puerto Rico nor available to level funded members in District of Columbia, Hawaii, Vermont and Puerto Rico.EI20445653.1
© 2024 United HealthCare Services, Inc. All Rights Reserved.Ways to earn rewards16Health Management | UHC Rewards EI232734050Get rewarded when you:Dollars earned:$300$25$25$10$10$2.50$50$15$2.50$5$2.50$0.50$0.25Connect a trackerDaily activity — goal 1: Track 15 active minutes or 5K steps per dayDaily activity — goal 2: Track 30 active minutes or 10K steps per dayFitness challenge: Track 30 active minutes or 10K steps, 5 out of 7 daysTrack 14 nights of sleepSleep challenge: Get 7 hours of sleep, 5 of 7 nightsTake a health surveyGet a biometric screeningGo paperlessComplete a 24/7 Virtual VisitGet a flu shotGet an annual checkupMaximum annual incentive
© 2024 United HealthCare Services, Inc. All Rights Reserved.One Pass Select17One Pass Select is a fitness membership and healthy lifestyle program designed to help you reach your wellness goals.The program allows you to: • Choose from thousands of gym locations, classes and activities — all in 1 program • Enjoy a variety of digital fitness apps • Fund your membership using earned UnitedHealthcare Rewards dollars or your own personal dollars
© 2024 United HealthCare Services, Inc. All Rights Reserved.Quit For LifeTools and coaching to help you kick tobacco for good• Live Tobacco-Free course and Quit For Life® app• Personalized action plan from your Quit Coach®• 24/7 urge management support • Text2Quit® encouragement textsThe Quit For Life Program provides information regarding tobacco cessation methods and related well-being support. Any health information provided by you is kept confidential in accordance with the law. The Quit For Life Program does not provide clinical treatment or medical services and should not be considered a substitute for your doctor’s care. Please discuss with your doctor how the information provided is right for you. Participation in this program is voluntary. If you have specific health care needs or questions, consult an appropriate health care professional. This service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room.18EI20445653.2
© 2024 United HealthCare Services, Inc. All Rights Reserved.Real Appeal19Real Appeal is a voluntary weight management program that is offered to eligible members at no additional cost as part of their benefit plan. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical and/or nutritional advice. Participants should consult an appropriate health care professional to determine what may be right for them. Results, if any, may vary. Any items/tools that are provided may be taxable and participants should consult an appropriate tax professional to determine any tax obligations they may have from receiving items/tools under the program.Healthier habits for a healthier youOur proven online weight management support program offers:• Online coaching – Encouragement to help create healthy, lasting change• Success Kit – Scales, recipes and fitness equipment delivered to your door• Motivational resources – Set achievable nutrition, exercise and weight management goalsEI20445653.2
© 2020 United HealthCare Services, Inc. All rights reserved.Thank YouQ & AQuestions: Please contact Tom Madden and/ or Susie Prokop, Account Manager at: 920-569-250820
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