MEDICAL BENEFITS Fund Name: Teamsters and Food Employers Security Trust Fund SPD Version: January 1, 2015

Transcription

1 MEDICAL BENEFITS Fund Name: SPD Version: January 1, 2015 Fund ID: L500 Revised: 1/29/18 RG Who is Covered: Active Members, Retirees & Dependents Trust Fund Contact Information To access eligibility, claim status, summary of benefits for medical, dental and/or vision as well as to contact the Trust Fund Office for general questions, please visit out Provider Portal or send us an Correspondence and Appeals: PO Box 2340 West Covina, CA Mail Medicare Claims to: PO Box 1618 San Ramon, CA Medicare claims also crossover through a Medicare clearinghouse. Mental Health & Substance Abuse Network (E-MAP): HMC Health Works Member: (800) Provider: (855) Mail claims to: PO Box El Paso, TX Electronic Payor ID: (Aetna & PPO members utilize HMC) Podiatry Network: Podiatry Plan of CA (PPOC) Find a PPO Provider: In California (800) Outside of CA (800) , or Mail all podiatry claims to: 203 Willow St., #204 San Francisco, CA or fax: (415) PPO Medical Network: Anthem Blue Cross Pre-certification: (800) Pricing: (800) Find a PPO Provider: Mail medical claims to: Anthem Blue Cross PO Box Los Angeles, CA EDI Payor ID: Group#: Alpha Prefix: GBU Chiropractic Network: American Specialty Health Network (ASHN) Members: (800) Providers: (800) Mail ASHN claims to: PO Box San Diego, CA Mail out-of-network claims to local Blue Cross. Our System is ICD-10 Compliant for Claims after 10/1/15 HMO Medical Option: (Not administered by BeneSys) Kaiser (800) *Kaiser Members use BMR Rx unless drug is on the Kaiser Base list. HMO Medical Option: (Not administered by BeneSys) Aetna Active: (877) Retirees: (888) Plan Name: Aetna Value Network HMO Active Grp: , Early-Retiree Grp: , Medicare Retiree Grp: Prescription Benefit Management: Broadreach Medical (BMR) (Not administered by BeneSys) Retail: ProCare Rx (877) Ext. 4 Mail Order: OptumRx Page 1 of 12

2 Benefit Appeals Timely Filing Claims Timely Filing PPO Medical Summary of Benefits: Comment Claimant will have 180 days from the date of denial. 1 year from the date of the service. Coordination of Benefits Active Employee / Early Retiree (Non-Medicare Primary) Medicare Primary Retirees If the primary plan has a PPO negotiated rate, this Plan (as secondary) will pay the difference between what is paid by the primary plan up to the maximum amount negotiated in the PPO contract. This Plan will not coordinate with any HMO coverage. This Plan as a secondary will pay 20% of Medicare s allowable. Participant will need to satisfy this Plan s deductible. This Plan will deny any services Medicare denies and deems not medical necessary. Any services that is typically covered under this Plan and is not a covered service under Medicare, will be covered under this Plan. Prior authorization is not required when Medicare is primary, unless it is a service that is not covered by Medicare, and this Plan has a prior authorization requirement for that service (e.g. home infusion therapy will require prior authorization by this Plan). Except for copayments and deductibles which result in out-of-pocket expenses for the Participant, this Plan will not pay benefits for expenses covered by HMO coverage. Dependent Age Limit Up to age 26. Should you or your Dependent be disabled on the date your coverage terminates, Hospital, medical and surgical benefits will be continued for you or your Dependent, with respect to such Disability only, provided that: 1. The Plan is in effect when the expense is incurred. Disabling Conditions Only 2. the disability continues until treatment is received. 3. Hospital confinement commences within 3 months of the termination of coverage. 4. the surgical procedure is performed within 3 months of the termination of coverage. 5. The medical treatment is covered within any part of the 3 month period immediately following the termination date. In no event will the benefit provided under this section extend beyond the 3 months following the Participant's loss of coverage. Grandfathered Status This Plan is not grandfathered. Plan Year January 1 through December 31. Traveling Outside of the United States Non-emergency and elective services outside of the United States are not covered. Participants cannot assign benefits to a Provider for services rendered outside the United States or its territories. Benefit In-Network Out-of-Network (UCR) Comment/Limitation Annual Maximum None In-network and out-of-network deductibles satisfy each other. Deductible $300 individual / $900 family Applicable to primary Medicare members. Deductible Carry Over Last 3 months (October, November, December). Page 2 of 12

3 Lifetime Maximum $900 per person None Per person out-of-pocket maximum includes deductible, mental health & substance abuse. Out-of-Pocket Maximum Effective 1/1/17: $14,300 None Effective 1/1/16, family out-of-pocket maximum includes medical and prescription drugs. Abortion (Voluntary) Effective 1/1/16: Prior to 1/16: family out-of-pocket maximum includes medical, mental health & $13,700 per family substance abuse, and prescription drugs. Plan requires a signed lien and TPL in order to review claims for possible payment but it does not require the auto dec page or police report. Accident If 2 or more eligible members are injured in the same accident, the covered expenses which result from the accident will be combined and only one deductible will be charged regardless of the number of family members injured. If the same accident results in covered expenses in the next calendar year, another single deductible only will be applied for these expenses. Work Related MVA 80% Fight 80% Accidental Dental 80% Acupuncture Allergy Services Injections 80% Testing 80% Must be medically necessary. Ambulance Effective 3/1/17, all covered ambulance services accumulate to the out-of-pocket maximum. Air 80% 80% Ground 80% 80% Birth Control See the Routine/Preventive Section under Contraceptives. Biofeedback 80% EEG Biofeedback for Mental Health Disorders is not covered. Chiropractic This Plan uses a Closed Panel of Chiropractors through the American Specialty Health Network (ASHN). Members: (800) Providers: (800) ashcompanies.com If a non-ashn provider is used, where a ASHN provider is available, the service is not covered. If there is no ASHN Provider in the county where services are received, benefits will be paid at 80% UCR after the deductible and the visit limits below apply: The ASHN Network is limited to: 12 visits 1st Month Page 3 of 12

4 Arizona, California, New Mexico, Nevada, Oregon, Utah & Washington. 8 visits 2nd & 3rd month 4 visits 4th month (Further treatment subject to review) In-network claims do not apply to the deductible and Blue Cross providers are out of network and receive out-of-network benefits. out-of-pocket. Mail out-of-network claims to local Blue Cross. Mail ASHN claims to: ASHN PO Box San Diego, CA Office Services Massage Therapy Modalities X-Ray Court Ordered Treatment Dental 80% Accidental injury to natural teeth only. Orthognathic Diabetic Supplies 80% Diagnostic Labs / X-Rays 80% ONE-TIME exception per employee or dependent: Lab ordered by a PPO Provider at a Non-PPO laboratory will be covered at 80%. DME costing $1,000 and over require prior authorization. Durable Medical Equipment (DME) 80% Stockings, CPAP & Supplies are covered with review of Medical Necessity. Corrective shoes are not covered. See Routine/Preventive section for breast pump benefits. Compression Stockings 80% Diabetic Shoes/Inserts 80% Educational or Training Programs, except as provided under the Routine/Preventive Section. Emergency Care Emergency Facility 80% 80% Emergency Physician 80% 80% Emergency Misc. 80% 80% Emergency with Admit. 80% 80% Urgent Care Facility 80% 80% Urgent Care Physician 80% 80% Urgent Care Lab/X-Rays 80% 80% Services provided in an ER or Urgent care facility which are not due to an Emergency shall be covered as an Office visit with a Physician and the facility charges shall not be covered. Page 4 of 12

5 Urgent Care Misc. 80% 80% Extended Care Facility See Skilled Nursing Facility. Custodial care is not covered. The Plan requires the use of a Podiatry Plan of California (PPOC) panel provider (including Medicare primary participants). Find a PPOC provider go to or call In California: , Outside California: If there is no PPOC provider in the area, the out-of-network podiatrists can contact PPOC and sign up under a "special contract" for one patient. Foot Care (Routine) NOTE: Although there are no specific limitations set forth by the Plan, if denied by PPOC the member will need to appeal to PPOC and then appeal to the BOT if still denied. Guidelines for the foot care benefit are determined medically necessary by PPOC. Mail podiatry claims to: PPOC 203 Willow St., #204 San Francisco, CA OR via fax: Medicare claims do not crossover to PPOC. Submit claims and Medicare EOB to PPOC. Routine foot care is not covered. Foot Care Must be medically necessary due to an underlining medical condition. Deductible does not apply. Prior authorization through PPOC is required. Orthotics / Supports Deductible does not apply. Genetic Testing Not covered, except as provided under the Routine/Preventive Section. Hearing Aids Office Visits / Testing 80% Home Health 80% Must be in lieu of hospitalization. Prior authorization is required. Home Infusion 80% Prior authorization is required. Must be in lieu of hospitalization. Hospice 80% Must be recommended by the attending physician. Prior authorization is required. Page 5 of 12

6 Bereavement 80% Hospital Inpatient admission requires prior authorization. Room & Board 80% Standard semi-private room rate. Inpatient Physician 80% ICU/CCU 80% Ancillary 80% Inpatient Pathology 80% Inpatient Radiology 80% Inpatient Surgery 80% Pre-Admission Testing (If done within 7 days prior to admission for approved Hospital stay. Duplicate pre-admit tests done in the hospital not covered) Infertility Injections 80% Maternity Care Dependent-child maternity is not covered except as provided under the Routine/Preventive Section. Pre/Post Natal Care Delivery 80% Newborn Nursery 80% Midwife 80% Birthing Center 80% Home Birth Mental Health & Substance Abuse All Retirees and their dependents enrolled in the Indemnity PPO Plan, and Aetna Medicare retirees and Medicare dependents of Aetna retirees are NOT eligible for Mental Health & Substance Abuse. Kaiser members must use Kaiser s benefits. Mental Health & Substance Abuse network (E-MAP): HMC Health Works To locate a Preferred Provider or to obtain approval/precertification call: (800) All inpatient services, non-routine outpatient surgeries such as electric convulsive treatment, psychological testing, neuropsychological testing require precertification. Other outpatient services may require pre-approval. Providers are required to call HMC to verify if services need approval/precertification. If approval/precertification is not obtained where it is required, benefits will not be paid. Eating Disorders are covered under Mental Health. Deductible does not apply. PPO out-of-pocket accumulates to the $900 out-of-pocket. Submit Aetna & PPO Claims: HMC Health Works PO Box Page 6 of 12

7 El Paso, TX Electronic Payor ID: Aetna Plan Participants Aetna Inpatient $350 per admission copay In-network copays are paid to the provider. Aetna Outpatient $20 copay Out-of-network charges are not covered, unless of an emergency. PPO Plan Participants (Active Plans Only) Inpatient Physician Inpatient Semi Private Rm Outpatient Physician Residential/Day Treatment Group Therapy/Family/Marriage Applied Behavioral Analysis (ABA) Therapy Emergency Care Anesthesia for Electric Convulsive Treatment Ambulance (Emergency room, ambulance, urgent care facility) HMC must be notified within 1 day of an Emergency inpatient admission. (to hospital for mental health treatment & substance abuse) Nursing Care 80% Private Duty Nursing is not covered. Precertification is required. Morbid Obesity/ 80% Bariatric Surgery Must be medically necessary. Page 7 of 12

8 Pre/Post-Operative office visits for approved surgery are covered, however records may be requested for review of lap-band adjustments to verify that patient still meets criteria. Office Visits Primary Care Physician 80% Specialists 80% Online Office Visit through Live Health Online 80% N/A (See the Routine/Preventive Section for services covered under ACA.) Home visits are not covered. Effective 11/1/15: Available through Visits are subject to the deductible. Deductible and coinsurance will accumulate towards the out-of-pocket. Patient pays their coinsurance with a credit card at the time of the visit. Pain Management 80% Prosthetics 80% Prosthetics Bra 80% Wig Routine/Preventive Adult & Women No Coverage for Out of Network Preventive Services (except Pap and Mammogram). Routine Exam Well-Woman Visits (to receive services below for women under 65) Abdominal Aortic Aneurysm (one-time screening for men ages who have ever smoked) Alcohol Misuse Screening/Counseling Anemia Screening (on a routine basis for pregnant women) Aspirin (Through the Prescription (To prevent cardiovascular disease for men ages & women ages 55-79) Plan) Blood Pressure Screening (for all adults) Breast Cancer Genetic Test (BRCA) Counseling (for women at higher risk of breast cancer) Breast Cancer Mammography Screening (every 1-2 years for women over 40) Breast Cancer Chemoprevention Counseling (for women at higher risk) Page 8 of 12

9 Breastfeeding Comprehensive Support/Counseling (from trained provider for pregnant/nursing women) Breast Pump/Supplies (for pregnant and nursing women) (for sexually active women) Cervical Cancer Screening Effective 1/1/18 the following limitations are applicable: (PAP) Ages covered every 3 years. Ages 30-65, HPV testing with pap smear every 5 years, or a pap smear alone every 3 years. Chlamydia Infection Screening (for younger women, and women at higher risk) Cholesterol Screening (Adults over age 50) Colorectal Cancer Screening Contraception (Oral contraceptive through the Prescription Plan) (FDA approved contraceptive methods, Sterilization procedures, and patient education and counseling as prescribe by a health care provider for women with reproductive capacity. Not including abortifacient drugs. This does not apply to health plans sponsored by certain exempt "religious employers".) Depression Screening (for all adults) Diabetes (Type 2) Screening (for adults with high blood pressure) Diet Counseling (for adults at higher risk of chronic disease) Domestic/Interpersonal Violence Screening/Counseling (for all women) Folic Acid Supplements (Through the Prescription (for women who may become pregnant) Plan) Gestational Diabetes Screening (for women who are weeks pregnant and those at high risk of gestational diabetes) Gonorrhea Screening (for all women at higher risk) Hepatitis B Screening (for pregnant women at first prenatal visit) HIV Screening (for everyone ages and those at high risk) Human Papillomavirus (HPV) DNA Test (every 3 years for women with normal cytology results who are 30 or older) Immunization Vaccines (Also through the Prescription Plan) (For adults. Doses, recommended ages, and recommended populations vary) Hepatitis A & B, Herpes Zoster (shingles), Human Papillomavirus (Gardasil), Influenza (flu shot), Measles Mumps & Rubella (MMR), Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella (chicken pox) Obesity Screening/Counseling (for all adults) Osteoporosis Screening (for women over age 60 depending on risk factors) Rh Incompatibility Screening (for all pregnant women and follow-up testing for women at higher risk) Page 9 of 12

10 Sexually Transmitted Infection (STI) Prevention Counseling (for adults at higher risk & sexually active women) Syphilis Screening (for adults at higher risk, and sexually active women) Tobacco Use Screening (for all adults, and expanded counseling for pregnant tobacco users) Tobacco Cessation (Through the Prescription Interventions Plan) (for tobacco users. Also covered at a pharmacy through Rx benefits) Urinary Tract/Other Infection Screening (for pregnant women) Routine/Preventive - Children No Coverage for Out of Network Preventive Services (except Pap and Mammogram). Alcohol and Drug Use Assessments (for adolescents) Autism Screening (for children at 18 and 24 months) Behavioral Assessment (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years) Blood Pressure Screening (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years) Cervical Dysplasia Screening (PAP) (for sexually active females) Depression Screening (for adolescents) Developmental Screening (for children under age 3) Dyslipidemia Screening (for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years) Fluoride Chemoprevention Supplements (Through the Prescription Plan) (for children without fluoride in water source) Gonorrhea Preventive Medication (for the eyes of all newborns) Hearing Screening (for all newborns) Height, Weight and Body Mass (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, Index Measurements 11 to 14 years, 15 to 17 years) Hematocrit or Hemoglobin Screening (for children) HIV Screening (for adolescents at higher risk) Hypothyroidism Screening (for newborns) Immunization Vaccines (Also through the Prescription Plan) (for children from birth to age 18 doses, recommended ages, and recommended populations vary) Diphtheria, Tetanus, Pertussis, Haemophilus influenzae type b, Hepatitis A & B, Page 10 of 12

11 Human Papillomavirus (Gardasil), Inactivated Poliovirus, Influenza (Flu Shot), Measles, Meningococcal, Pneumococcal, Rotavirus, Varicella. Iron Supplements (Through the Prescription (for children ages 6-12 months at risk of anemia) Plan) Lead Screening (for children at risk of exposure) Medical History (for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years) Obesity Screening/Counseling Oral Health Risk Assessment (for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years) Phenylketonuria (PKU) Screening (for this genetic disorder in newborns) Sexually Transmitted Infection (STI) Prevention Counseling/Screening (for adolescents at higher risk) Tuberculin Testing Vision Screening Respite Care (for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years) (for all children) Must be billed as a preventive visit. Prior authorization is required. Skilled Nursing Facility 80% If Medicare is primary and did not deny, no prior authorization is required under this Plan. Up to 100 days. Sleep Apnea Sleep Study/Titration 80% Smoking Cessation See Routine/Preventive Section Under "Tobacco Use." Sterilization Female Only. Not Subject to Deductible. Tubal Ligation Vasectomy Reversal Surgery If no precertification is obtained, claim will pay at. Inpatient Facility 80% Inpatient Physician 80% Outpatient Facility 80% Office Procedure 80% Page 11 of 12

12 Assistant Surgeon 80% (Payable at 80% IF surgery done in a PPO Hospital) CRNA 50% 50% Phys. Assistant 65% 65% Anesthesiology 80% (Payable at 80% IF surgery done in a PPO Hospital) TMJ (By an MD only) 80% ASC 80% up to $1,000/day Refractive Eye Surgery Therapy/Rehabilitative Frequency and Limitations for Physical/Occupational/Speech only. Rx required Fax (626) Frequency of treatment begins with 1st day of treatment and is per diagnosis. 1st month 3 treatments per week 2nd month 2 treatments per week 3rd month 1 treatment per week 4th month 2 treatments per month Any treatment exceeding the frequencies listed above will require review of medical necessity. Submit request for additional visits with all progress notes and Rx via fax to: PHT (626) Physical Therapy 80% Occupational Therapy 80% Speech Therapy 80% Cardiac Rehab 80% Pulmonary 80% Radiation 80% Chemo 80% Developmental Transplants Transplants R & B 80% Transplant Organ Procedure 80% Transplant Fees 80% Donor Search Licensed Speech Therapist only. Limited to therapy for speech lost or impaired due to sickness or injury. Page 12 of 12