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Frequently Asked Questions
Obtain answers to commonly asked questions related to Medicare, your plan, and UnitedHealthcare®.
This plan has a wider network of providers, comparable to UC Medicare PPO and UC High Option plans. Your copay for out-of-network services is the same as if you had stayed in-network as long as Medical provider accepts the UnitedHealthcare® Medicare Advantage PPO plan and has not opted out of or been excluded or precluded from the Medicare Program, and the services are covered benefits and medically necessary Evidence of Coverage (EOC) page 3-3 for definition of medically necessary.
Members can see Behavioral Health providers who have opted out of Medicare for Medicare-covered outpatient behavioral health services; however, UC Medicare Choice members will need to submit claims via the Direct Member Reimbursement process. For information on this process, please contact UnitedHealthcare toll-free at 1-866-887-9533, 8 a.m. – 8 p.m. PT, Monday through Friday. TTY users, call 711.
What are UC’s eligibility rules to enroll into UC Medicare Choice?
You must be enrolled in Medicare Part A and Medicare Part B to participate in this plan. You must continue paying your Medicare Part B premium to Social Security to continue to maintain your eligibility for coverage under the UC Medicare Choice plan.
University of California Eligibility, Enrollment, Termination and Plan Administration Requirements
The University establishes its own Medical Plan enrollment and termination criteria based on the University of California Group Insurance Regulations and any corresponding Administrative Supplements.
Retirees
Information pertaining to your eligibility, enrollment, cancellation or termination of coverage and conversion options can be found in the “Group Insurance Eligibility Fact Sheet for Retirees”. A copy of this fact sheet is available in the HR Forms & Publications section of UCnet. Additional resources are also in the Compensation and Benefits section of UCnet to help you with your health and welfare plan decisions.
If you stop paying Social Security Administration (SSA) for your Part B and/or Part D (IRMAA) premiums, the University of California will be notified that you are no longer eligible for the Medicare plan. UC will then move you to a non-Medicare plan, stop any Part B reimbursement and charge you a significant penalty per month while you are not enrolled in Medicare. The premium for the non-Medicare plan is typically higher than the premium for the Medicare plan. To re-enroll, you may be required to re-assign your Medicare to your UC plan. Your non-Medicare plan will be terminated if you do not re-enroll in Medicare promptly.To re-enroll in Original Medicare, contact the Social Security Administration by phone 800-772-1213 or online at ssa.gov.
IRMAA stands for Income Related Monthly Adjustment Amount. Similar to Medicare Part B, high income earners will pay more for their Medicare Part D prescription drug coverage. If you are a member of a Medicare plan that includes prescription drug coverage and your Modified Adjusted Gross Income on your IRS tax return from two years ago is above a certain amount, you may pay an additional amount for Medicare Part D coverage. The extra amount is paid directly to Social Security, not to UC or your medical plan. If you are subject to IRMAA, Social Security will send you a letter. The letter will explain how they determined the amount you must pay and the actual IRMAA amount. Neither the University of California nor your health plan determine who will be subject to IRMAA. Therefore, if you disagree with the amount you must pay, contact the Social Security Administration. You can:
- Go online to the Social Security Administration website
- Call Social Security toll-free at 1-800-772-1213, TTY 1-800-325-0778 between 7 a.m.–7 p.m., local time, Monday–Friday
- Visit your local Social Security office
Yes, you must be enrolled in Medicare Part A and Medicare Part B to participate in this plan. You must continue paying your Medicare Part B premium to Social Security to continue your eligibility for coverage under the UC Medicare Choice plan.
Network providers have a contract with UnitedHealthcare. Out-of-network providers do not have a contract. With this plan, you have the flexibility to see any provider (in-network or out-of-network) at the same cost share, as long as they are willing to accept UHC payment schedule and have not opted out of or been excluded from Medicare. If you contact UnitedHealthcare, we will be happy to reach out to your provider to discuss how the plan works and how they will be paid.
Yes, UC Medicare Choice is a UnitedHealthcare® Group Medicare Advantage PPO plan plan that allows you to see any Medicare participating provider in the country with the same benefits and copays. You must be a permanent resident of California to be eligible for the plan. The permanent address provided to the University of California will be used to determine your eligibility for this plan. Retirees living or moving outside of California may have coverage through UC’s Medicare Coordinator Program administered by Via Benefits. Please see the links below for more information.
If your Medical doctor has opted out of the Medicare program in its entirety, you would only have coverage in an emergency. Less than 1% of doctors nationally have opted out/not signed up for the Medicare program. If you need help finding a doctor in our network, call UnitedHealthcare Customer Service toll-free at 1-866-887-9533, TTY 711, 8:00 a.m.–8:00 p.m. PT, Monday through Friday. If you want additional choices, go to www.Medicare.gov/physiciancompare for a listing of doctors who participate in Medicare.
Please note that UC Medicare choice provides comprehensive behavioral health coverage. Members can see Behavioral health providers who have opted out of Medicare for Medicare covered outpatient behavioral health services on a direct member reimbursement basis. For Example, Members can see state licensed Marriage Family Therapists and Marriage Family Child Counselors for Medicare covered outpatient behavioral health services.
UC Medicare Choice plan includes over 67,000 national chain, regional, local and independent neighborhood pharmacies in the UnitedHealthcare network, including University of California Medical Center pharmacies. You can look up pharmacies online at retiree.uhc.com/uc, and once you become a member, you can request a printed pharmacy directory by calling UnitedHealthcare Customer Service at the number on your UnitedHealthcare member ID card. You can also call UnitedHealthcare Customer Service to check if a pharmacy is in-network, or to get pharmacy contact information.
Individuals with Medicare who do not join a Medicare drug plan when they are first eligible, and who don't have prescription drug coverage that is at least as good as standard Medicare prescription drug coverage (creditable drug coverage) may pay a Late Enrollment Penalty (LEP) if they join a Medicare drug plan later. Individuals must pay the LEP if they join a Medicare drug plan after having a period of 63 days or longer without Medicare prescription drug coverage or other creditable prescription drug coverage after they are first eligible to join. The LEP is an original part of the Medicare Part D program launched in 2006. Individuals will be responsible to pay a penalty for every month they were eligible to join a Medicare drug plan and were not enrolled in one. This penalty is in addition to their monthly premium for as long as they are enrolled in a Medicare drug plan. The late enrollment penalty amount is at least 1% of the "base beneficiary premium" (the national average premium) for each full uncovered month someone was eligible to join a Medicare drug plan and did not. Because the "base beneficiary premium" can change annually, the LEP amount can ALSO change annually. Members will receive an annual notification of annual changes to LEP amounts.
If you have received a letter or have questions about the Medicare Part D Late Enrollment Penalty, please call UnitedHealthcare Member services toll-free at 1-866-887-9533, TTY 711, 8:00 a.m.–8:00 p.m. PT, Monday through Friday. Please note that you have 90 days (from the original date of the letter) to work directly with UnitedHealthcare and attest to having creditable coverage. Member service advocates can provide specific LEP amounts and are not permitted to make an estimate of Late Enrollment Penalty amounts. CMS assesses the penalty amount and there are several factors affecting the determination.
Generally, Medicare beneficiaries who are qualified to join a prescription drug plan, or Part D, but choose not to enroll during their initial enrollment period, may be subject to a late enrollment penalty. These fees were intended to encourage Medicare beneficiaries to sign up for a drug coverage plan when they first become eligible. Therefore, if someone does not apply when first eligible for coverage and Medicare assigns them a late enrollment penalty, this Medicare penalty stays with the person no matter what Medicare drug plan they enroll in. The plan must enforce and collect the late enrollment penalty.
The Centers of Medicare and Medicaid Services receives the money collected for the Late Enrollment Penalty.
You may need a new prescription beginning with your UC Medicare Choice effective date. The Plan Details Book that you receive following your enrollment in the plan will include Pharmacy Home Delivery contact information. You may want to refill your pharmacy home delivery prescriptions before the end of this year so you have time to get your new prescription in place.
Annual out-of-pocket maximum works by placing limits on how much money you pay out-of-pocket for your health care expenses in a given calendar year. This does not include plan premiums. Under the UC Medicare Choice plan, $1,500 is the maximum out-of-pocket medical expense and $2000 is the maximum out-of-pocket expense for prescription drugs. Once you reach your maximum out-of-pocket expense, you will no longer be required to pay any co-pay or co-insurance for covered medical care and prescription drugs for the remaining plan year.
Every drug on the plan’s Drug List is in one of 4 cost-sharing tiers. In general, the higher the cost sharing tier, the higher your cost for the drug:
Tier 1 – Preferred Generic - All covered generic drugs.
Tier 2 – Preferred Brand - Many common brand name drugs, called preferred brands.
Tier 3 – Non-preferred Drug - Non-preferred brand name drugs. In addition, Part D eligible compound medications are covered in Tier 3.
Tier 4 – Specialty Tier - Unique and/or very high-cost brand drugs.
The UC Medicare Choice plan requires you or your doctor to get prior approval for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used and covered correctly by Medicare for your medical condition.
Some Part D eligible drugs must be billed to the Medicare Part B benefit depending on patient-specific circumstances including diagnosis, patient location, and/or level of care being provided (e.g., long-term care, hospice care). Depending on how the drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how the drug will be used to make sure it’s correctly covered by Medicare. If you don’t get prior approval, the plan may not cover the drug.If you have questions about how the drug you are currently taking is covered by your plan, call UnitedHealthcare Customer Service toll-free at 1-866-887-9533, TTY 711, 8:00 a.m.–8:00 p.m. PT, Monday through Friday.
If you have a limited income, you may be able to get Extra Help to pay for your prescription drug costs. If you qualify, Extra Help could pay up to 75% of your drug costs or more. Many people qualify and do not know it. There is no penalty for applying and you can re-apply every year. Call Social Security toll-free at 1-800-772-1213, TTY 1-800-325-0778, between 7 a.m.–7 p.m., local time, Monday–Friday.
Whether your provider is in-network or out-of-network, your provider can submit claims to UnitedHealthcare online. The UnitedHealthcare claim address information is provided on your UnitedHealthcare Member ID card and in your Plan Details Book. UnitedHealthcare processes claims payments for out-of-network providers in compliance with all federal regulations.
None. Under this plan, you are not responsible for any balance billing when seeing health care providers who are participating in Medicare. If the doctor does not participate or has opted out of Medicare, call UnitedHealthcare and they will help you to find another doctor participating in Medicare and/or willing to bill UnitedHealthcare.
There are many hospitals in the UnitedHealthcare network. For a full list of hospitals, contact UnitedHealthcare Customer Service toll-free at 1-866-887-9533, TTY 711, 8:00 a.m.–8:00 p.m. PT, Monday through Friday. Note that UnitedHealthcare Customer Service will only be able to provide a list of hospitals within the UnitedHealthcare network. Remember, since this is a PPO plan, the hospital does not have to be in the network in order for you to receive services under this plan. You may choose to go to the hospital of your choice.
There is no limit to the number of days covered for hospital admission. Days are unlimited.
If you are enrolled in this plan and have family members who are not Medicare-eligible, they can remain or will be enrolled in UC Blue & Gold HMO, which will be the “partner plan” for the UC Medicare Choice plan.
Your UnitedHealthcare Member ID card should arrive within 14 days from Medicare approving your enrollment. If your enrollment has been approved by Medicare and you have not received your ID card, contact UnitedHealthcare Customer Service toll-free at 1-866-887-9533, TTY 711, 8:00 a.m.–8:00 p.m. PT, Monday through Friday.
To access care, you will only need to use your UnitedHealthcare Member ID card for all covered medical, behavioral health and prescription drug services. It is important that you use your UnitedHealthcare Member ID card each time you receive medical services or fill a prescription. Since UnitedHealthcare pays all claims directly, the claims no longer go to Medicare first. Always show your UnitedHealthcare Member ID card to ensure that your claims are processed correctly, timely and accurately. Make sure to put your Medicare card somewhere for safekeeping.
No, this Medicare Advantage plan is not the same as what is advertised on TV. UC Medicare Choice is a custom Group Medicare Advantage PPO plan designed exclusively for University of California Medicare retirees who reside in California. This plan is different and should not be confused with individual UnitedHealthcare Medicare Advantage plans that might be available in the area through an Exchange.
We encourage you to review the What to Do When You Need Care brochure on the Resources page.
UC Medicare Choice is a Medicare Advantage PPO plan administered by UnitedHealthcare. This plan combines your Medicare Part A, B and D coverage into one single plan. When you enroll in this plan, you agree to let UnitedHealthcare provide your Medicare coverage. UC Medicare Choice provides coverage for Medicare Parts A, B, and D. As a result, you do not need to enroll in any other plan.
Be aware that when you turn 65 years old, you may receive various notifications (letters, e-mails, phone calls, brochures, etc.) from other insurance companies or on products that are not associated with UC Medicare Choice. Most of these notifications are sent during the Medicare Annual Enrollment Period to all Medicare-eligible and Medicare-enrolled persons. Remember: Enrolling in these other Medicare plans will automatically disenroll you from UC Medicare Choice.
The most recent list of services for which UnitedHealthcare requires our in-network doctors to request a prior authorization is below. Important to note:
- This list changes periodically
- Members are never held responsible for prior authorizations, including if they were not requested by their in-network doctor prior to a service being performed
- In-network providers are responsible for requesting prior authorizations and are already doing so under their contract with UnitedHealthcare
- Out of network providers and the members using them are not required to request any prior authorizations
Current Prior Authorization Listing
- Behavioral health services
- Bone growth stimulator
- Breast reconstruction (non-mastectomy)
- Cardiology
- Cardiovascular
- Cochlear implants and other auditory implants
- Cosmetic and reconstructive procedures
- Durable medical equipment if greater than $1000
- Gender dysphoria treatment
- High cost medication for inpatient Skilled Nursing Facility
- Hysterectomy
- Injectable chemotherapy
- Injectable medications
- Intensity-Modulated Radiation Therapy
- Non-emergency transport - air or ground
- Orthognathic surgery
- Orthopedic surgeries
- Orthotics
- Potentially unproven services
- Prosthetics
- Radiology
- Rhinoplasty
- Sleep apnea procedures and surgeries
- Spinal stimulator for pain management
- Stereotactic body radiation therapy
- Stereotactic radiosurgery
- Therapeutic radiology services
- Vagus nerve stimulation
- Transplant of tissue or organs
- Vein procedures
- Ventricular assist devices
- Inpatient Admissions – Post-Acute Services.
Hospital admissions are not subject to prior authorization, but we do request notification within one day of admission. Acute inpatient rehabilitation is subject to prior authorization. Rehabilitative therapies, however, are not broadly subject to prior authorization.
Surgical procedures, such as a biopsy, done in a doctor’s office, will have a doctor’s office visit co-pay apply ($20).
Surgical procedures, such as a biopsy, done in an ambulatory surgery center or outpatient hospital setting, will have the outpatient surgery co-pay apply ($100).
UnitedHealthcare pays the pathologist. There is no co-pay for pathology.
Important Note: Members have access to both In- and Out-of-Network providers. Cost-share to member is equivalent for both In- and Out-of-Network services (when the provider bills UnitedHealthcare directly).
Obtaining outpatient surgery, and other medical services at an Outpatient Hospital facility and Ambulatory Surgical Center may result in a $100 copayment when two of the following conditions are met: (1) the claim reflects an outpatient surgical center, Hospital, or Ambulatory surgical center as the place of service and (2) the claim indicates that a treatment room was provided to you at the time of service.
We recommend scheduling an appointment with your doctor at their office.
Verify that your provider can perform the same service at their office instead of an outpatient hospital setting. If so, a $20 office visit copay will apply, and not the $100 outpatient copayment.
Example: Shoulder injections require a $20 copayment at a doctor’s office and $100 copayment at an outpatient hospital facility. A $20 copayment will be applied when the surgical service takes place in a doctor’s office.
Please ask your doctor if the procedure will take place in an outpatient hospital setting or in a doctor’s office.
Out of network providers are not required to request pre-authorizations. The UC Medicare Choice plan covers services covered by Medicare plus additional benefits. If the service provided is a covered benefit under UC Medicare Choice, then a prior authorization is not required when rendered by out of network provider.
Medical service obtained overseas are handled on a reimbursement basis. You will pay the overseas provider at the time of service, and then submit a direct member reimbursement request to UnitedHealthcare directly. UnitedHealthcare will reimburse amounts you paid for your overseas care minus your copayment.
UnitedHealthcare does not require medical records to be submitted with foreign claims so we would pay this type of service using the statement from the hospital.
UnitedHealthcare pays foreign claims at the same benefit level that they pay domestic claims.
For example:
| Covered Benefit | Domestic (Copayment) | Overseas (Copayment) |
|---|---|---|
| Outpatient Surgery | $100 | $100 |
| Inpatient Hospital | $250 (per admit) | $250 (per admit) |
| Primary & Specialist office visit | $20 | $20 |
| Emergency | $65 (waived if admitted to the hospital) | $65 (waived if admitted to the hospital) |
| Urgent care | $20 (waived if admitted to the hospital) | $20 (waived if admitted to the hospital) |
When plan members pay for covered medical services out of pocket, they can submit a Medical Direct Member Reimbursement request to UnitedHealthcare for a refund of what they paid for covered medical services minus the copayment amount for the covered service provided. Medical Direct Member Reimbursement requests can be submitted for domestic medical services, overseas medical services, and behavioral health medical service. One form does it all. For convenience, you may also submit a Medical Reimbursement request online by signing into your member portal at www.retiree.uhc.com/uc. You may also contact UnitedHealthcare Customer Service to have a paper form mailed to you directly. Call 1-866-887-9533, 8 a.m. - 8 p.m. PT, Monday through Friday. TTY users, call 711.
Click on the links below to access the forms:
You should submit a medical direct member reimbursement request within 365 days from the date of service.
You can call UnitedHealthcare Customer Service using the phone number on your ID card. Alternatively, if you have access to a computer, you can also print a direct member reimbursement request form directly from the plan website(s). You do not need to be registered to access and print the medical direct member reimbursement form at www.retiree.uhc.com/uc.
Send the completed and signed direct member reimbursement request form to the medical claims address on the ID card
Please keep in mind that the Medical direct member reimbursement request form is used for medical services obtained in the United States, medical services obtained overseas, and behavioral health services obtained from a non-Medicare provider. UnitedHealthcare will reimburse what you paid minus the applicable copayment for the covered services provided.
For reimbursement for medical services obtained within the United States, include:
- Medicare Provider
- Medicare-covered Service
- Proof of Payment such as paid invoice, receipt, credit card statement, etc.
For reimbursement for medical service while traveling overseas, include:
- Proof of Payment such as paid invoice, receipt, credit card statement, etc.
- Note: Translation and currency conversion not required
For reimbursement for Behavioral Health Services obtained from non-Medicare providers, include:
- Medicare-covered service was provided
- Proof of payment such as paid invoice, receipt, credit card statement, etc.
- Complete direct member reimbursement form (Paper or online)
If approved, you will receive a check within 30-60 days from receipt. If not approved, expect to receive a letter within 30-60 days from receipt. Direct member reimbursement requests may be denied for various reasons (e.g., not submitted on time, insufficient or incomplete documentation and/or information, not a covered benefit, etc.). If the direct member reimbursement request is denied, you will receive a letter from UnitedHealthcare stating the reason why it was denied and a statement about your right to appeal the decision.
No. Treatment obtained from medical providers who opted out of Medicare is only covered in emergency situations. However, UC Medicare Choice provides coverage for Medicare covered behavioral health services when provided by behavioral health providers such as Marriage and Family Therapists (MFT) and Marriage Family and Child Counseling (MFCC) who opted out of Medicare.
Yes. The UC Medicare Choice plan offers identical In- and Out-of-Network benefits for Medicare covered services. The provider just needs to be willing to bill UnitedHealthcare for the Medicare covered service(s) provided.
Yes, if these providers have not formally opted out of Medicare. UC Medicare Choice offers identical In- and Out-of-Network benefits for Medicare covered services. The provider just needs to be willing to bill UnitedHealthcare for the Medicare covered service provided.
Yes. UC Medicare Choice provides comprehensive behavioral health coverage. UC Medicare Choice provides coverage for Medicare covered behavioral health services from Medicare participating providers for a $20 office visit copayment. These Medicare participating providers will bill the plan directly so that you do not need to pay anything other than the $20 copayment for the Medicare covered behavioral health service received.
In addition, UC Medicare Choice also extends coverage for behavioral health services obtained from providers who do not participate in Medicare. For example, Medicare covered services provided by Marriage and Family Therapists (MFT) and Marriage Family and Child Counseling (MFCC) are covered under UC Medicare Choice on a Direct Member Reimbursement basis. If you receive Medicare covered services from non-Medicare participating behavioral health providers, you will need to pay upfront at the time of service, and then submit a Medical Direct Member Reimbursement request to UnitedHealthcare. UnitedHealthcare will reimburse 100% of what you paid minus the $20 office visit copayment.
At this site, you can learn more about the custom programs offered to plan members by visiting our Virtual Education Center. You can watch videos from UnitedHealthcare Medicare Advantage plan members speaking about their experience as well as print additional program information. No log in is required, and you can access the site using a tablet, computer, or smartphone.
Visit uhc.com/covid-19 to access additional information on COVID-19. Here are some of the resources available:
- Find COVID-19 coverage information.
- Learn About COVID-19 vaccine authorized by the FDA
- Check Your Symptoms
- Find Diagnostic Testing Center
- Talk your doctor using Telehealth Services
- Taking care of yourself
- Our response to COVID-19
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in these plans depends on the plan’s contract renewal with Medicare.
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