HF TPA Vision Care Rider $15/$75 Exam Plus

Transcription

1 In consideration of the receipt of supplemental premium within established time frames, the following benefit for vision services is added to and made a part of the Health First Health Benefit Plan (herein called the Group Plan), subject to all the terms and conditions set forth in this Rider. This Rider is effective for the Plan Year listed on the ERISA Information page of the Summary Plan Description. This Vision Care Rider provides information about coverage for routine vision care, which is excluded under your medical health care plan, and remains in force in conjunction with the underlying Group Plan. All provisions in the Group Plan Summary Plan Description apply, unless specifically indicated otherwise below. Please call Customer Service at (855) for information about coverage, questions or complaints. Health First Health Plans (hereinafter referred to as the Health Plan) agrees to provide the vision services described under the provisions of this Vision Care Rider. ELIGIBILITY UNDER THIS RIDER To be eligible for coverage under this Vision Care Rider, you must be properly enrolled and included for coverage under the employer s Group Plan, as set forth in the Summary Plan Description. When dependents are added to or removed from an employee s medical plan, the same enrollment changes are made to coverage under this Vision Care Rider. In the event your medical plan coverage terminates, all benefits cease under this Vision Care Rider. COVERED SERVICES Routine Vision Examination 1 In-Network Out-of-Network One (1) Routine Vision Examination per calendar year $15.00 copayment Not covered Each covered person is entitled to one (1) Routine Vision Examination per calendar year from a Participating Provider. The examination shall include case history, visual acuity (clearness of vision), external examination and measurement, internal examination with an ophthalmoscope, pupillary reflexes and eye movements, retinoscopy (shadow test), subjective refraction, coordination measure (far and near), medicating agents for diagnostic purposes and tonometry (measurement of intraocular pressure). The routine vision examination copayment shall count toward the out-of-pocket maximum expense limit set forth in your Schedule of Benefits. Vision Hardware Adults 19 Years of Age and Older In-Network Out-of-Network Eyeglasses or contact lenses allowance (per calendar year) $75.00 Frames and prescription lenses 20% discount Not applicable Contact lens fittings 50% discount Not applicable 1 Vision examinations involving treatment of disease or injury of the eyes are covered under the Group Plan s medical benefit, as set forth in your Summary Plan Description. The Specialist Office Visit cost-share listed in your Schedule of Benefits will apply.

2 Pediatric Vision Hardware Up to Age 19 In-Network Out-of-Network Eyeglasses (limited to 1 pair per calendar year if allowance is not chosen) OR $0 copayment Not covered Eyeglasses or contact lenses allowance (per calendar year if pair of eyeglasses are not chosen) $75.00 Frames and prescription lenses 20% discount Not applicable Contact lens fittings 50% discount Not applicable Each covered person nineteen (19) years of age and older is entitled to an allowance in the amount of $75.00 each calendar year for the purchase of eyeglasses (frames and eligible prescription lenses) or contact lenses from a Participating or Non-Participating Provider. This allowance serves as a reimbursement benefit, meaning the covered person will pay the cost of the eyeglasses or contact lenses at the time the materials are furnished and then submit the applicable form and supporting documentation for reimbursement to the Health Plan. See the Filing a Claim for Benefits section below for more information. Eligible lenses: This Rider will include coverage for single vision, bifocal and trifocal lenses. Frames: Covered persons may select from a wide variety of frames that hold prescribed lenses. Pediatric vision hardware benefits are covered up through the end of the calendar year in which the covered person reaches age nineteen (19) when provided by a Participating Provider. Pediatric enrollees are covered for one (1) pair of standard child frame and basic lenses per calendar year. Eligible prescription lenses include single vision, bifocal and trifocal lenses. Pediatric vision services or materials that are not furnished by a Participating Ophthalmologist, Optometrist or Optician are not covered. OR Pediatric enrollees may select an allowance in the amount of $75.00 each calendar year for the purchase of eyeglasses (frames and eligible prescription lenses) or contact lenses from a Participating or Non-Participating Provider. This allowance serves as a reimbursement benefit, meaning the covered person will pay the cost of the eyeglasses or contact lenses at the time the materials are furnished and then submit the applicable form and supporting documentation for reimbursement to the Health Plan. See the Filing a Claim for Benefits section below for more information. Eligible lenses: This Rider will include coverage for single vision, bifocal and trifocal lenses. Frames: Covered persons may select from a wide variety of frames that hold prescribed lenses. Each covered person will receive a discount of 20% towards the purchase of frames and prescription lenses and a 50% discount on the Health Plan s negotiated allowable amount for contact lens fittings when received from a Participating Provider. At the time of purchase, you will pay the cost of the materials, less the applicable discount. See the Plan Covered Services section of your Summary Plan Description for information on medically necessary eyeglasses and lenses covered under the Group Plan s medical benefit.

3 EXCLUSIONS AND LIMITATIONS In addition to the general exclusions and limitations listed in the Summary Plan Description, this Vision Care Rider does not cover services or materials connected with or charges arising from: Services or materials that are not furnished by a participating Ophthalmologist, Optometrist or Optician. (Exception: The vision hardware allowance for adults 19 years of age and older may be used towards the purchase of materials received from Participating or Non-Participating Providers.) Orthoptic, vision training, eye exercises or educational instruction and materials. Services for which benefits are payable under Florida worker s compensation law or any other law of similar purpose, whether benefits are payable for all or only part of the charges. Non-prescription materials, including non-prescription sunglasses and reading or magnification glasses. Vision examinations or materials required as a condition of employment or which the employer is required to provide in compliance with a labor agreement or state or federal law. Services or materials furnished prior to the effective date or after the termination date of coverage. Medical and/or surgical treatment of the eye, eyes, or supporting structures. (Such services may be covered under the Group Plan s medical benefit. See the Summary Plan Description for details.) Replacement of lost, stolen or damaged materials. Athletic or industrial lenses. For example, athletic goggles are not covered. More than one (1) Routine Vision Examination per calendar year. Mailing and/or shipping and handling expenses. FILING A CLAIM FOR BENEFITS A claim is any request for plan benefits made in accordance with the claim procedures described herein and as set forth in the Claim Provisions section of the Summary Plan Description. The Health Plan will provide or arrange for covered services to be received from Participating Providers through a contractual arrangement. At the time covered services are rendered, you will pay the fixed, discounted fee. When purchasing vision hardware, you will pay the cost of the materials (less the applicable discount if purchased from a Participating Provider) and must submit a request for reimbursement to the Health Plan. To submit a request for reimbursement, complete the following steps: 1. Complete a Medical Reimbursement form. This form is available on the Health Plan s website at and through the Health Plan s Customer Service Department.

4 2. Attach an itemized receipt of the services or supplies rendered, along with a written proof of payment made. 3. Mail the written Medical Reimbursement form and supporting documentation to the following address within six (6) months following receipt of the service or materials: Health First Health Plans ATTN: Benefits Reimbursement Unit 6450 US Highway 1 Rockledge, FL Claims submitted after the six (6) month deadline will be denied. In the event a claim is denied, in whole or in part, an insured has a right to appeal, as set forth in the Complaint, Grievance and Appeal Procedures section of the Summary Plan Description. DEFINITIONS Ophthalmologist means a licensed physician who specializes in the treatment of disorders of the eye. Optician means a licensed professional who fits clients with prescription eyeglasses or contact lenses, assists clients in the selection of eyeglass frames, arranges for the production of eyeglasses or contact lenses and mounts lenses in eyeglass frames. Optometrist means a licensed physician authorized by the Board of Optometry to administer and prescribe topical ocular pharmaceutical agents and licensed pursuant to Chapter 463 of the Florida Statutes. Participating Provider means, or refers to, the preferred Provider Network established and so designated by the Health Plan which is available to covered persons. For purposes of this Vision Care Rider, this includes a licensed Ophthalmologist, an Optometrist operating within the scope of his or her license, or a dispensing Optician who has made an agreement with the Health Plan to provide services to covered persons and is published as such in the Health Plan s Provider Directory. Vision Examination means a vision testing exam, including a determination as to the need for correction of visual acuity and prescribing lenses, if needed, which is performed by a licensed Ophthalmologist or Optometrist who is operating within the scope of his/her license. A vision examination (including dilation, if necessary) includes the following procedures: Case history, including patient medical/eye health history, record of current medications, record of visual acuities with/without present correction, if applicable. Pupil responses, external exam findings, internal exam findings, screening of visual fields perception, and binocular and ocular mobility testing. Retinoscopy (when applicable), subjective refraction at far and near point. Test of accommodation and/or near point refraction. Tonometry (measurement of intraocular pressure). Diagnosis/prognosis and/or specific recommendations. MISCELLANEOUS PROVISIONS

5 Nothing contained herein shall be held to vary, alter, waive, or extend any of the terms, conditions, provisions, or limitations of the Summary Plan Description to which this Rider is attached, other than as specifically stated herein. This Rider shall supersede any rider providing coverage for vision care previously issued by the Health Plan. In the event of any conflict between the provisions of this Rider and the Summary Plan Description, the provisions of this Rider will prevail. All other terms and conditions of the Summary Plan Description shall remain in full force and effect.