2013 uny conference health benefit summariesunyumc.s3.amazonaws.com... · problem, about budget...

2013 UNY CONFERENCE HEALTH BENEFIT SUMMARIES The following changes are being implemented for January 1, 2013. Information will continue to be communicated throughout the coming months. Health Reimbursement Account (HRA) Each participant will have $250 credited to a Health Reimbursement Account. If the participant has two person coverage or family coverage, there will be $500 deposited in the account. This is to help offset the higher deductible and co-payments implemented in 2012 which continue in 2013. A Health Reimbursement Account (HRA) is similar to a Flexible Spending Account (FSA), except that it is NOT “use it or lose it”. Account balances can be rolled over year to year and can even be used in retirement.

The HRA is funded by the Conference, and may be used to pay for eligible out-of-pocket health-related expenses including co-payments, co-insurance, dental care, vision care including glasses or contact lenses, prescription medications, and other expenses that are eligible under Flexible Spending Account (FSA) guidelines.

Participants will receive a Ceridian Benefit Card, which is used much like a debit card. Those who are currently participating in an FSA will retain their current card. 2013 amounts will be “loaded” onto it at January 1. Benefits Card usage requirements and rules are the same for both the FSA and the HRA—EXCEPT for people with both an FSA and an HRA, the FSA always pays first.

FSA—flexible spending account. Participants may choose to set aside their own pre-tax money into an FSA. The FSA may be used to pay for eligible out-of-pocket health related expenses, including co-payments, co-insurance, dental care, vision care including glasses or contact lenses, prescription medications, and other expenses that

are eligible under FSA guidelines.

HRA—health reimbursement account (also called a health reimbursement arrangement). The HRA is funded by the Conference through HealthFlex, and may be used to pay for eligible out-of-pocket health-related expenses including co-payments, co-insurance, dental care, vision care including glasses or contact lenses, prescription medications, and other expenses that are eligible under FSA guidelines.

More information and a training opportunity will be communicated this fall.

Under Age 65 participants and/or family members: Remain in HealthFlex EPO D with no medical plan changes. Medco RX benefit structure will change to a percentage co-payment. See summary.

Over Age 65 Participants and/or family members: Transition to AmWins Medicare supplemental medical and RX plan. See summary.

Vision Plan: Remains the same for all participants and family members. Full coverage benefit through VSP.

4074/081911

2012 EPO – Option D

Health plan administered by Blue Cross and Blue Shield of Illinois (BCBSIL): 1-866-804-0976; orHealth plan administered by UnitedHealthcare (UHC): 1-800-901-1939Pharmacy plan administered by Medco Health: 1-800-841-2806Behavioral health plan administered by United Behavioral Health (UBH): 1-800-788-5614

Page 1 of 4

Lifetime Benefit Maximum None

Annual Deductible (Participant pays, if applicable)2

Co-payments are not included in the annual deductible.

Note: Prescription drug coverage is subject to a separateannual deductible.

If satisfied HealthQuotient (HQ) requirement

• $500 per person• $1,000 per family

If did not satisfy HQ requirement*

• $750 per person• $1,250 per family3 (children only)• $1,500 per family3 (spouse or spouse and children)

* Annual deductibles must be satisfied before the Plan pays benefitsdescribed below.

Annual Out-of-Pocket Limit or Co-Payment Maximum None

Co-insurance (Plan pays) See individual benefit co-payments below.

Primary Care Physician Office VisitsPrimary care physicians include internists,general practitioners, family practitioners,obstetricians, gynecologists and pediatricians.

• $30 co-payment per visit, then Plan pays 100%

Plan Feature Participating Provider Benefits Only1

Plan’s Share vs. Participant’s ShareThe annual deductible, co-payments and annual out-of-pocket limit are the participant’s share to pay.All other percentage “benefits” are amounts the Plan(HealthFlex) pays.

1 The Plan will not pay any benefits when you obtain services from Non-Participating Providers, other than in cases of emergency. For Emergency Services,you might pay more than the co-payment amount defined in the Plan for services obtained from Non-Participating Providers since you will be responsiblefor any charges that exceed the Maximum Allowance.

2 Higher Medical Plan Deductible Provisions (Generally, applicable to individuals participating in HealthFlex before April 1, 2011—more details about theHQ requirement are provided online at www.gbophb.org; click on “HealthFlex/WebMD” and then select “2011 Incentives: Frequently Asked Questions.”)

• Effective January 1, 2012, any participant with individual coverage who did not complete the HealthQuotient (HQ) health risk assessment between August 1and September 30, 2011 will be subject to the $250 higher deductible.

• Effective January 1, 2012, any participant who covers their dependent child(ren) but not a spouse and did not complete the HQ between August 1 andSeptember 30, 2011 will be subject to the $250 higher deductible. Every covered dependent in the family unit will also have the $250 higher deductible.However, the family deductible will not increase by more than $250.

• Effective January 1, 2012, any participant with family coverage (including a spouse) who did not complete the HQ between August 1 and September 30, 2011will be subject to the $250 higher deductible. Every covered dependent in the family unit will also have the $250 higher deductible. However, thefamily deductible will not be more than $500 higher.The same higher deductibles would occur if the participant took the HQ between August 1 andSeptember 30, 2011 but the covered spouse did not.

3 The family deductible is the total of all charges applied toward the deductible for the primary participant and their covered dependents. Once this totalequals the annual deductible amounts shown, the family deductible has been satisfied for the balance of the plan year.

Caring For Those Who Serve

1901 Chestnut AvenueGlenview, Illinois 60025-16041-800-851-2201www.gbophb.org

DebiMarshall

Typewritten Text

DebiMarshall

Typewritten Text

____

DebiMarshall

Typewritten Text

2013

Outpatient Short-Term Rehabilitative Therapy• Physical therapy• Occupational therapy• Speech therapy

Physical and occupational therapy: Combined $6,000calendar year maximum.Speech therapy: $4,000 calendar year maximum.

• $30 co-payment per visit, then Plan pays 100%• $30 co-payment per visit, then Plan pays 100%• $30 co-payment per visit, then Plan pays 100%

Specialist Office Visits • $50 co-payment per visit, then Plan pays 100%• Allergy injections only: Plan pays 100%

Preventive Care4

Well Child Benefits (Under age 16)• Includes charges for office visits, age-appropriate

immunizations and routine diagnostic tests. Thereis a one visit per year maximum for childrenage 2 and older.

Well Adult Benefits (16 and Over)• One well person exam annually, including charges

for an office visit, routine mammogram, pap smear,prostate exam, routine blood work and colorectalscreening for cancer.

• Colonoscopy (Covered once every three years forparticipants age 45 and older.)

• 100%

• 100%

• 100%

Licensed Dietitian4

• Office visit • $30 co-payment per visit, then Plan pays 100%

Outpatient Diagnostic Services and Treatment• Physician office

• Hospital, independent lab and x-ray facility

• $30 co-payment if PCP, then Plan pays 100%;$50 co-payment if specialist, then Plan pays 100%

• 100%

Outpatient Services/Ambulatory Surgery • $500 co-payment per admission, then Plan pays 100%

Inpatient Hospital CarePre-notification required. Verify with physician.

• $750 co-payment per admission, then Plan pays 100%• Co-payment waived if participant is readmitted within

30-day period for same condition

Emergency and Urgent Care ServicesNotification required within 48 hours if admitted

• Primary Care Physician office visit

• Specialist Physician office visit

• Hospital emergency room

• Urgent care facility or outpatient facility

• Ambulance



• $200 co-payment* then Plan pays 100%5

• $100 co-payment* then Plan pays 100%5

• 100%5

* Waived if admitted

Page 2 of 4

4 Due to the federal health care reform legislation enacted in 2010, certain preventive services in this benefit category may be paid at a different benefit level.If you wish to know what these services are, contact your medical plan provider (BCBSIL: 1-866-804-0976 or UHC: 1-800-901-1939).

5 Only in the case of a “true emergency” as defined in the Plan. If not a true emergency, there is no benefit payable.


TransplantPre-notification required. Verify with physician.

100% at a Blue Distinction Center for Transplant (BCBSIL)or United Resource Network facility (UHC)

Maternity Care/Physician Charges4

Enroll during the first trimester for education and supportthroughout the pregnancy.• BCBSIL: 1-866-804-0976• UHC: 1-800-901-1939

Pre-notification required. Verify with physician.

• $30 co-payment for first visit to confirm pregnancy,then Plan pays 100% for all subsequent prenatal visits,postnatal visits and delivery

Newborn Routine Nursery Inpatient Services4 • 100%

Alternative Therapies• Chiropractic care• Massage therapy• Acupuncture• Naprapathy

Combined $1,000 calendar year maximum.

• $30 co-payment per visit, then Plan pays 100%• $50 co-payment per visit, then Plan pays 100%• $50 co-payment per visit, then Plan pays 100%• $50 co-payment per visit, then Plan pays 100%

Special Services• Skilled Nursing Facility: 120 days maximum per

calendar year

• Private Duty Nursing:- $2,000/month maximum (BCBSIL)- $24,000 annual maximum (UHC)

• Home Health Care: 60-visit maximum per calendar year

• Hospice

Pre-notification required. Verify with physician.

• 100%

• 100%

• 100%

• 100%

Hearing Benefit• Hearing aids – Every 24 months• Exam

• 50% up to $500 per ear (no deductible)• $50 co-payment, then Plan pays 100%

Pre-Notification and Medical Management ReviewBCBSIL: 1-866-804-0976UHC: 1-800-901-1939

It is recommended that you always coordinate your carethrough your Primary Care Physician (PCP).

To ensure maximum benefits, pre-notification is requiredfor certain services. Please see the HealthFlex BenefitBooklet for a complete list or call the number for yourClaims Administrator on the left.

Verification of Benefits for Behavioral Health ServicesUBH: 1-800-788-5614

To ensure maximum benefits for behavioral healthservices, please see the United Behavioral Health benefitsummary and certificate of insurance for information, orcall the number for UBH on the left.

Page 3 of 4


of 4

MaximumAllowance All benefit payments for covered services, includingEmergency Services, rendered by Participating andNon-Participating Providers are limited to the MaximumAllowance for the service, as determined by BCBSIL orUHC based on Reasonable and Customary amounts.

Participating Providers, or Network Providers, havesigned an agreement with BCBSIL or UHC to accept theMaximum Allowance as payment in full. ParticipatingProviders have agreed not to bill for amounts in excessof the Maximum Allowance.

Non-Participating Providers, or Non-Network Providers,have not signed an agreement with BCBSIL or UHC toaccept the Maximum Allowance as payment in full.Therefore you are responsible for the difference betweenthe Maximum Allowance and the Provider’s charge whenusing a Non-Participating Provider.

This summary highlights some of the features of this benefit plan.The summary is for illustrative purposes only and is subject to change at anytime.The controlling terms and conditions of the benefit plan are contained in the Plan Document, Summary Plan Description and theHealthFlex Benefit Booklet (collectively, the “Documents”) maintained by the General Board of Pension and Health Benefits. If there are anyconflicts between this summary and the terms of the Documents, the terms of the Documents shall control.

Please note: Some plan provisions may be subject to change, based on pending provisions of federal health care legislation.


Important Note for BCBSIL Out-of-Area (OOA) Participants:In order to receive maximum benefits under the Plan, you must notify BCBSIL to have your provider approved as a ParticipatingProvider before any non-emergency services are rendered. However, in the case of a true emergency, you should seek assistancefrom the closest health care provider; such emergency services will generally be covered if otherwise eligible under the Plan.

If you have questions about whether you are an OOA participant, please contact the Health Team at 1-800-851-2201.

DebiMarshall

Typewritten Text

____

DebiMarshall

Typewritten Text

2013

3149/071211 Me

Caring For Those Who Serve

1901 Chestnut Avenue

Glenview, Illinois 60025-1604

1-800-851-2201

www.gbophb.org

2012 UBH Employee Assistance Program and Behavioral Health — Standard EPO Benefit

Administered by United Behavioral Health (UBH): 1-800-788-5614

Managed Mental Health Participating Provider Benefit Non-Participating Provider Benefit*

Employee Assistance Program

(EAP)

Eight visits at 100% coverage with

pre-certification

N/A

Outpatient

Mental Health

Chemical Dependency

$15 co-payment per visit, then the Plan

pays 100%

$15 co-payment per visit, then the Plan

pays 100%

Plan pays 60%

Plan pays 60%

Intermediate Care

Mental Health

Chemical Dependency

Plan pays 100%

Plan pays 100%

Plan pays 60% after $300 co-payment

per admission


per admission

Inpatient

Mental Health

Chemical Dependency

Plan pays 100%

Plan pays 100%


per admission


per admission

Out-of-Pocket Maximum N/A N/A

Lifetime Maximum None

* Any and all benefits paid are subject to Reasonable & Customary charge provisions—meaning charges are limited to the Maximum Allowance

under the Plan and covered individuals will be responsible for amounts in excess of the Maximum Allowance as determined by UBH. Please Note: To ensure that you receive the maximum benefits available under the Plan, you should contact UBH at 1-800-788-5614 prior to receiving care. If the services are rendered as the result of an emergency, you or a family member should contact UBH within 48 hours. (continued)

DebiMarshall

Typewritten Text

____

DebiMarshall

Typewritten Text

2013

Additional Information:

• Out-of-network benefits (outpatient) are subject to usual and customary rates.

• Out-of-network benefits (inpatient and intermediate care) are subject to retrospective review for medical necessity if not

pre-authorized by UBH.

• In-network benefits (inpatient and outpatient) are subject to clinician/facility contracted rate.

• Due to state law, benefits may be slightly different for residents of Kansas.

• To receive the highest benefit available, all services must be provided by Mental Health/Substance Abuse (MHSA) specialists

who are in the UBH network of participating providers. If you should have any questions, please call UBH at

1-800-788-5614.

Additional services available through the UBH EAP include:

• Legal Assistance—An initial 30-minute phone or in-person consultation with a local attorney or mediator (one per separate

matter) at no cost. Additional services are available at a 25% discount with network attorneys and mediators.

• Financial Services—Credentialed financial counselors provide free phone consultations, not to exceed 60 minutes per

problem, about budget planning, debt consolidation, investments and other financial issues. These services include referrals to

local financial professionals and advisement resources, as well as a free document review service for budget plans, loan

paperwork and more.

• Adult/Elder Support Services—Resources for people caring for adult and elder dependents, including caregiving and

housing options, chronic illness support, transportation and meal services, and senior activity groups.

• Child/Parenting Support Services—Extensive services for families and children up to age 18, such as information and

answers to parenting questions, plus resources for day care, summer camp, adoption, sick-child care and more.

• Life Learning Support Services—Educational resources for all ages and abilities, including help with locating and

evaluating schools, finding classes for special-needs children and arranging tutoring services.

• Chronic Condition Support Services—Valuable information and support services for employees and dependents who have a

chronic condition like diabetes, arthritis or asthma.

There is no limit on the use of these EAP services unless otherwise noted.

This summary highlights some of the features of this benefit plan. The summary is for illustrative purposes only and is subject to change at any time. The controlling terms and conditions of the benefit plan are contained in the Plan Document, Summary Plan Description and the certificate of insurance issued by United Behavioral Health (collectively, the “Documents”). If there are any conflicts between this summary and the terms of the Documents, the terms of the Documents shall control.

General Board of Pension and Health Benefits of The United Methodist Church and VSP provide you an affordable eyecare plan.

Full Service Plan Your Coverage with a VSP Doctor

Doctor Network: VSP Signature WellVision Exam® focuses on your eye health and overall wellness • $20 copay ....................................every 12 months

Prescription Glasses • $20 copay

Lenses...................................................every 12 months • Single vision, lined bifocal, and lined trifocal lenses • Polycarbonate lenses for dependent children

Frame....................................................every 24 months • $120 allowance for a wide selection of frames • 20% off the amount over your allowance

~OR~ Contact Lens Care • No copay .....................................every 12 months

$120 allowance for contacts and the contact lens exam (fitting and evaluation). If you choose contact lenses you will be eligible for a frame 12 months from the date the contact lenses were obtained. Current soft contact lens wearers may qualify for a special program that includes a contact lens exam and initial supply of lenses.

Extra Discounts and Savings Glasses and Sunglasses • Average 35 - 40% savings on all non-covered lens

options • 30% off additional glasses and sunglasses, including

lens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last WellVision Exam

Contacts • 15% off cost of contact lens exam (fitting and

evaluation) Laser Vision Correction • Average 15% off the regular price or 5% off the

promotional price. Discounts only available from contracted facilities.

• After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor

Your Coverage with Other Providers Visit vsp.com for details, if you plan to see a provider other than a VSP doctor. Exam..................................................................Up to $50 Single vision lenses ...........................................Up to $50 Lined bifocal lenses ...........................................Up to $75 Lined trifocal lenses .........................................Up to $100 Frame.................................................................Up to $70 Contacts ...........................................................Up to $105

VSP guarantees service from VSP doctors only. In the event of a conflict between this information and your organization's contract with VSP, the terms of the contract will prevail.

2013 AmWins Medical Coverage Summary

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

Services Medicare Pays Medigap Pays You Pay

Hospitalization*: Semi-Private room and board, general nursing and miscellaneous services & supplies:

First 60 Days All but $1,156 $1,156 (Part A Deductible) $0

61st through 90

th day All but $289 per day $289 per day $0

91st through 150

th day

While using 60 lifetime reserve days:

Additional 365 days:

All but $578/day

$0

$578 per day

100% of Medicare-Eligible

Expenses

$0

$0

Skilled Nursing Facility Care*: Semi-Private room and board, skilled nursing and rehabilitative services and other services and supplies.

First 20 days

21st through 100

th Day

All Approved Amounts

All but $144.50 per day

$0

Up to $144.50 per day

$0

$0

Blood: When furnished by a hospital or skilled nursing facility during a covered stay.

First 3 Pints

Additional Amounts

$0

100%

100%

$0

$0

$0

Hospice Care: Pain Relief, symptom management and support services for terminally ill

Available as long as your doctor certifies that

you are terminally ill and you elect to receive

these services

100% for hospice care

All but $5 for prescription drugs

95% for inpatient respite care

$5 for prescription drugs

5% for inpatient respite care

$0

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

Services Medicare Pays Medigap Pays You Pay

Medical Expenses: In or Out of the Hospital and Outpatient Hospital Treatment, such as Physician’s services, inpatient and outpatient

medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment:

First $140 of Medicare-approved Amounts $0 $0 $140 (Part-B

Deductible)

Remainder of Medicare-approved Amounts Generally 80% Generally 20% Up to $20 copay

for some doctor’s

office visits and up

to $50 copay for

ER visits that don’t

end in an

admission

Part B Excess Charges (above Medicare-

approved amts.)

$0 $0 All Costs

Clinical Laboratory services, blood tests,

urinalysis and more

100% $0 $0

Blood:

First 3 Pints $0 100% $0

Additional Amounts $0 $0 $140 (Part B

Deductible)

Remainder of Medicare-approved Amounts Generally 80% Generally 20% $0

2013 AmWins Medical Coverage Summary

MEDICARE (PARTS A & B)

Services Medicare Pays Plan Pays You Pay

Home Health Care: Medicare Approved Services:

Medically necessary skilled care

services and medical supplies

100% $0 $0

Durable Medical Equipment:

First $140 of Medicare Approved

Amounts**

Remainder of Medicare Approved

Amounts

$0

Generally 80%

$0

Generally 20%

$140 (Part B

Deductible)

$0

OTHER BENEFITS – NOT COVERED BY MEDICARE

Foreign Travel Emergency***:

Deductible – First $250 each calendar

year

$0 $0 $250**

Medically necessary emergency care

services beginning during the first 60

days of each trip outside the US.

$0 80% to lifetime maximum

of $50,000

20% and

amounts over

the $50,000

lifetime

maximum.

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out

of the hospital and have not received skilled care in any other facility for 60 days in a row.

**Once you have been billed $140 of Medicare-Approved amounts for covered services (which are noted with an asterisk),

your Medicare Part B Deductible will have been met for the calendar year.

***Foreign Travel coverage deductible is a separate deductible, and does not apply to the calendar year deductible or the

Part A or B Deductible.

The summary of program benefits described herein is for illustrative purposes only. In case of differences or errors, the

Group Policy governs.

Prescription Drug Summary - $100 Plan Deductible for 2013

Under the Patient and Protection and Affordability Care Act (PPACA), manufacturers are required to subsidize the

prescription plan for 50% of the cost of brand-name drugs after your drug costs reach $2,930 in 2012. By taking

advantage of this payment, we are able to modify the remaining benefits of your plan so that you will pay the same brand-

name drug co-payment, while reducing the overall monthly premium amount.

2013 POST-65 RX PLAN

ANNUAL RX DEDUCTIBLE - $100

$100-$2,930

Drug Types Plan Pays PRESCRIPTION

Manufacturers Pay

Amount You Pay 90 Day Mail Order

Tier 1

Generics All but $10 $0 $10 $20

Tier 2

Preferred Brand All but $20 $0 $20 $50

Tier 3

Non-preferred brand

& Specialty

All but $35 $0 $35 $87.50

AMOUNTS OVER $2,930 IN PRESCRIPTON COSTS

Drug Types Plan Pays PRESCRIPTION

Manufacturers Pay

Amount You Pay 90 Day Mail Order

Tier 1

Generics All but $10 $0 $10 $20

Tier 2

Preferred Brand 50% less $20 50% $20 $50

Tier 3

Non-preferred brand

& Specialty

50% less $35 50% $35 $87.50

This plan offers full coverage through the coverage gap (or “doughnut hole”). You are simply required to

pay the above co-pay amounts only for each prescription. There is a $100 initial deductible. Once you

pay a total of $4,700 in RX co-pays during the calendar year, the plan then pays 95% of remaining

prescription costs. This plan is a “creditable coverage” Medicare Part D Prescription Drug Plan.