Health Care Benefits Handbook

Transcription

1 Health Care Benefits Handbook For HI, BCC & PEG Associates Effective January 1, 2013 Choose Well. Live Well

2 Welcome...1 About This Handbook...3 About the Health Care Benefit Plans...3 Updated Information...4 About Your Employment...4 If You Have Questions...5 If You Need Help Understanding This Plan Document...5 Benefits at a Glance...7 Participating in the Health Care Plans...7 Medical Plans...10 Dental PPO Plan...11 Vision Care Plan...12 What Happens If...13 If I Get Married...13 If I Divorce...13 If I Become a Parent...14 If My Child Turns Age If My Child Is No Longer Eligible...15 If I Become Disabled...15 If I End My Employment...16 If I Die...16 Participating in Health Care Coverage...17 Who Is Eligible...17 Proof of Status...18 How and When to Enroll...19 Enrolling When First Eligible...20 Enrolling During Open Enrollment...20 Enrolling During the Year...20 Making Changes or Changing Your Coverage...22 What Coverage Costs...22 When Coverage Begins...23 What Happens If You Have Other Coverage (Coordination of Benefits)...24 Which Plan Pays First...24 How Much the Plan Pays...26 Subrogation and Reimbursement...26 Overpayment...27 When Coverage Ends...27 i

3 How to Continue Coverage...28 If You Take an FMLA Leave...28 If You Take a Uniformed Services Leave...29 Medical Coverage...31 Your Medical Plan Choices...31 Your Medical Options at a Glance...33 Using the PPO Plans...41 Network Providers...42 How to Pay for Your Care...43 Using the Consumer Choice Plans...49 Network Providers...50 How to Pay for Your Care...52 Other Features of the Medical Plans...57 Precertification...57 Retrospective Review...60 Case Management...61 Knowing What Is Covered and What Is Not...61 Medical Necessity...61 Eligible Expenses...62 Ineligible Expenses...76 How to File a Claim...80 Claim-Filing Deadline...80 Prescription Drug Coverage...81 How Your Prescription Drug Benefits Work...81 Your Prescription Drug Benefits at a Glance...82 How to Use Your Prescription Drug Benefits...83 In-Network Retail Pharmacies...83 CVS Caremark Mail Service Pharmacy...83 How to Pay for Prescription Drugs...85 How Prior Authorization Works...85 Knowing What Is Covered and What Is Not...86 Filing Claims...88 Claim-Filing Deadline...88 Dental Coverage...89 How the Dental PPO Plan Works...89 Your Dental Benefits at a Glance...90 Using the Dental PPO Plan...91 Preferred Dentists...91 Out-of-Network Dentists...91 ii

4 If Your Dependent Lives Away from Home...92 Paying for Your Care...92 Deductible...92 Coinsurance...93 Annual Benefit Maximum...94 Orthodontia Lifetime Maximum...94 An Example of How the Dental PPO Plan Works...95 Other Features of the Dental PPO Plan...95 Predetermination of Benefits...96 Alternate Benefits...96 Knowing What Is Covered and What Is Not...97 Eligible Expenses...97 Ineligible Expenses...99 Services and Supplies Dental Benefits After Coverage Ends How to File a Claim Claim-Filing Deadline Vision Coverage How the Vision Care Plan Works Your Vision Benefits at a Glance Using the Vision Care Plan In-Network Providers Out-of-Network Providers If Your Dependent Lives Away from Home Paying for Your Care Copay Maximum Reimbursement Amount An Example of How the Vision Care Plan Works Knowing What Is Covered and What Is Not Eligible Expenses Ineligible Expenses How to File a Claim Claim-Filing Deadline Continuing Coverage COBRA COBRA at a Glance Who Is Eligible for COBRA Enrolling for COBRA Coverage Cost of COBRA Coverage iii

5 Length of COBRA Coverage Additional Qualifying Events Special Rules for Disability Early Termination of COBRA Coverage Contacting the COBRA Administrator Extended Health Care Coverage Extended Health Care Coverage at a Glance Who Is Eligible for Extended Health Care Coverage Enrolling for Extended Health Care Coverage Cost of Coverage Length of Extended Health Care Coverage Early Termination of Extended Health Care Coverage Contacting the Extended Health Care Administrator Rules, Regulations, and Administrative Information Plan Documents Your Rights Under the Employee Retirement Income Security Act of 1974 (ERISA) Request for Eligibility Determination Benefit Claims Claims Review and Appeals Procedures Health Care Plans Non-assignment of Benefits Determining Payment of Benefits Correcting Mistakes in Payments Subrogation and Right of Recovery Subrogation Right of Recovery Your HIPAA Privacy and Security Rights Participating Associate Groups Change or Termination of the Plan Employment Rights Not Implied Other Plan Details Glossary Contact Information iv

6 Welcome to the Hillenbrand, Inc. Health Care Benefits Plan Document. Looking for information about your Company health care benefits? Then you have come to the right place. The Hillenbrand, Inc. Health Care Benefits Plan Document is the first place you should turn when you have questions about your benefits. This Plan Document is the official plan document for the Company s health care benefit plans, which are components of the Hillenbrand, Inc. Welfare Plan. It also serves as the summary plan description (SPD) of the health care plans, which is required by federal law. The Company reserves the right to amend, change, or terminate the plans, programs, and policies described in this Plan Document. This Plan Document governs the following health care benefits: If you are looking for an overview of your benefits, check out Benefits at a Glance. It briefly explains who is eligible for coverage, when coverage begins, and the benefits available to you as a Company associate. Medical and prescription drug coverage Dental coverage Vision coverage However, vision coverage is also governed by an insurance contract between the Company and Fidelity Security Life Insurance Company. If you cannot find the information you are looking for in this Plan Document, refer to Contact Information for important phone numbers and websites. Or, contact the Hillenbrand, Inc. Benefits Center with any questions you may have. 1

7 Welcome 2