Writers Guild-Industry Health Fund. Summary of Benefits

Transcription

1 Writers Guild-Industry Health Fund Summary of Benefits Effec tive January 1, 2016

2 This Summary of Benefit ( SOB ) booklet, along with the Summary Plan Description ( SPD ), will serve as your guide to the medical, vision, prescription drug, dental, mental health and chemical dependency benefits available to eligible participants in the Writers Guild-Industry Health Fund ( Fund ). The SOB contains details about (1) your earnings requirement, (2) dependent coverage premiums, (3) benefit levels for each plan, and (4) plan contact information. The SOB does not serve as a guarantee of benefits. Services are either subject to pre-authorization or medical necessity review. The benefits outlined in this booklet may change from time to time. Terms not specifically defined herein shall have the meaning assigned to them in the SPD. The Trustees reserve the right to terminate or change any part or all of any of the health plans offered under the Fund at any time. Benefit changes will periodically be communicated to you by letter, SMM, newsletter, or our website between publications of updates of this SOB. MEDICAL, MENTAL HEALTH AND CHEMICAL DEPENDENCY PPO PLAN LOW OPTION PLAN 1 PPO service area of 2 providers) 3, 4 PLAN FEATURES Calendar-Year Deductible 5 $300/person; $900/family Plans Out-of- $1,000/person 6 Pocket Maximum 7, 8 (coinsurance only) $300/person; $900/family $300/person; $900/family $750/person; $2,250/family $2,500/person $1,000/person $4,500/person 6 $750/person; $2,250/family $6,000/person (coinsurance only) (coinsurance only) (coinsurance only) (coinsurance only) ACA Out-of-Pocket Maximum 6, 7 Lifetime Maximum $6,850/person $13,700/family/yr (includes in-network deductible, coinsurance & copays) $6,850/person $13,700/family/yr (includes in-network deductible, coinsurance & copays) Unlimited Unlimited Unlimited Unlimited IMPORTANT! Note: All services are subject to medical necessity review at the time of payment. 1 For COBRA Participants and Extended Coverage participants only. Unlimited 2 Benefits for services received from a network provider will be paid based on the contracted rate. 3 Benefits for services received from non-network and out of area providers will be paid based on reasonable and customary (R&C) allowances. The participant is responsible for any amount over the R&C. 4 The participant must contact the Fund office to determine if the provider qualifies for the out-of-area benefit. If the provider is approved, the participant is responsible for filing claims with the Fund to receive benefit reimbursement. 5 All plan benefits are paid after the deductible, unless otherwise noted. 6 Once a person reaches the out-of-pocket maximum (OOP), the Plan pays 100% coinsurance of R&C allowances or the contracted rate, whichever applies, (but not co-payments) for eligible expenses for that person the rest of the year. The Affordable Care Act (ACA) required OOP maximums applies only to in-network services. The ACA OOP maximum accumulates the in-network deductibles, copayments and coinsurance for medical, hospital and prescription drugs. 7 The Plan s out-of-pocket maximum (after deductible) for Medicare-eligible Certified Retirees who retired prior to March 1, 1997, and are receiving a benefit from the Producer - Writers Guild of America Pension Plan of greater than $800 per month, is $400 for network providers (with coverage at 85%) and $600 for non-network providers (with coverage at ). 8 Both network and non-network charges apply toward the Plans out-of-pocket maximum, unless otherwise noted. 1

3 Eligibility Earnings Minimum (effective 7/1/13): $35,568 (One hour network prime-time story and teleplay) Eligibility Earnings Minimum (effective 7/1/14): $36,457 (One hour network prime-time story and teleplay) Eligibility Earnings Minimum (effective 7/1/15): $37,368 (One hour network prime-time story and teleplay) Eligibility Earnings Minimum (effective 7/1/16): $38,302 (One hour network prime-time story and teleplay) Premium for Dependent Coverage: $50 per month, payable quarterly, in advance Life Insurance Benefit for Active Participants and Certified Retirees: PPO Plan only. $5,000 MEDICAL, MENTAL HEALTH AND CHEMICAL DEPENDENCY PPO PLAN LOW OPTION PLAN 1 PPO service area of 2 providers) 3, 4 PHYSICIAN SERVICES Doctor s Office 85% 11 80% 11 Visit 9 60% Periodic Health Assessment Wellness 10, 11 Benefits Wellness Benefits 10 Wellness Benefits Well Baby Care 85% 11 80% 11 60% Childhood Wellness Visits, including Immunizations Through age 6 Ages 7 and older 85% 11 Wellness Benefits 10,11 Wellness Benefits 10 80% Wellness Benefits % Adult Immunizations Wellness 10, 11 Benefits Wellness Benefits 10 Wellness Benefits Includes lab work and X-rays. 10 See Wellness Benefits, page See Preventive Care Benefits Services, page 5. Some or all of the services in this section may be covered under the Preventive Care Service Benefits, payable at 100%, no deductible, when seen by a network provider. 2

4 MEDICAL, MENTAL HEALTH AND CHEMICAL DEPENDENCY PPO PLAN LOW OPTION PLAN PPO service area of 2 providers) 3, 4 PHYSICIAN SERVICES Maternity Care 12 85% 11 80% 11 60% Inpatient / Outpatient Physician Services Inpatient Routine Nursery Visits and Room and Board 14 Other Physician Services 85% 13 80% 13 60% 85% 80% 60% 85% 11 80% 11 60% Surgery 15 85% 80% 60% HOSPITAL SERVICES Emergency Room 85% after $50 copay (copay is waived if admitted; hospital admission copay applies) 18 after $50 copay (copay is waived if admitted; hospital admission copay applies) 80% 18 after $50 copay (copay is waived if admitted; hospital admission copay applies) Inpatient 85% after $100 Services 16, 17 after $100 80% after $100 after $50 copay (copay is waived if admitted; hospital admission copay applies) after $100 60% 18 after $50 copay (copay is waived if admitted; hospital admission copay applies) 60% after $100 Outpatient 85% 11 80% 11 60% Services 11, 17 Outpatient Lab Work and X-rays 85% 11 80% 11 60% Skilled Nursing 17, 23 Facility 85% after $100 after $100 80% after $100 after $100 60% after $ Includes prenatal care, delivery and postnatal care of a physician-delivered baby. 13 Non-network anesthesiologists, radiologists and pathologists are payable at 85% of R&C under the PPO plan or of R&C under the Low Option plan, if services are rendered at a network facility by a network physician. 14 Inpatient hospital copay applies to the facility fees associated with the baby s facility charges. 15 Assistant surgeons will be considered at a reduced benefit level that is equal to 20% of the surgeon s contract or R&C allowances. 16 Includes semi-private room and board within plan limits and ancillary services. 17 review is required for all inpatient and outpatient treatment facilities, such as partial hospitalization, residential treatment and intensive outpatient programs. 18 Emergency room services may qualify for network coinsurance if emergency care definition is met. See SPD for definition. 3

5 MEDICAL, MENTAL HEALTH AND CHEMICAL DEPENDENCY PPO PLAN LOW OPTION PLAN 1 PPO service area of 2 providers) 3, 4 OTHER MEDICAL SERVICES Alternative Medicine Acupuncture 19 Biofeedback 20 Chiropractic 21 85% of $60 allowable/visit; one monthly re-exam to monitor progress of $60 allowable/visit; one monthly re-exam to monitor progress 80%of $60 allowable/visit; one monthly re-exam to monitor progress of $60 allowable/visit; one monthly re-exam to monitor progress 60% of $60 allowable/visit; one monthly re-exam to monitor progress Lymphedema Therapy 20 Occupational Therapy 20 Osteopathic Manipulative Treatment Outpatient Physical Therapy 20 Orthoptic Training Ambulance 80% (emergency only) 80% (emergency only) 80% (emergency only) (emergency only) 60% (emergency only) Air or Sea Ambulance 85% (emergency only) (emergency only) 80% (emergency only) (emergency only) 60% (emergency only) Ambulatory Surgery Center 85% $1,500/ incident maximum 80% $1,500/ incident maximum 60% $1,500/ incident maximum Electro- Convulsive Therapy (ECT) 85% 80% 60% IMPORTANT! Note: All services are subject to review for medical necessity at the time of payment. 19 For chronic pain control only. 20 A referral is required from a doctor of medicine (M.D.). 21 Manipulation of the musculoskeletal system. 4

6 MEDICAL, MENTAL HEALTH AND CHEMICAL DEPENDENCY PPO PLAN LOW OPTION PLAN 1 PPO service area of 2 providers) 3, 4 OTHER MEDICAL SERVICES Enhanced External Counterpulsation Therapy (EECP) 85% 80% 60% Hearing Aids 50% copay 22 50% copay 22 50% copay 22 50% copay 22 50% copay 22 Home Health 23 Care and Home Infusion Therapy Hospice Care 23 Required - 85% Required - 85% Required - Required - Required - 80% Required - 80% Required - Required - Required - 60% Required - 60% Infertility Treatment Inversion Device 85%; $500 / per device and a Rx from an M.D. is required ; $500 / per device and a Rx from an M.D. is required 80%; $500 / per device and a Rx from an M.D. is required ; $500 / per device and a Rx from an M.D. is required 60%; $500 / per device and a Rx from an M.D. is required Preventive Care Services (See SPD for details) 100% of certain Preventive charges as identified by Federal Law Not available Not available 100% of certain Preventive charges as identified by Federal Law Not available Routine Mammograms Preventive Care 11 10, 24 Wellness Benefits 10, 24 Wellness Benefits Preventive Care 11 60% Under 35 Ages Age 40 & Over 1 every 5 years 1 every year 1 every 5 years 1 every year 1 every 5 years 1 every year 1 every 5 years 1 every year 1 every 5 years 1 every year IMPORTANT! Inpatient, outpatient facility, Home Health Care, Hospice, Home Infusion Therapy, Skilled Nursing Facility and Transplant Services must be preauthorized through Anthem Blue Cross. Network services that are considered Preventive Care Services as identified by Federal Law are not subject to a copay or annual deductible. For additional details, see the SPD or 22 Covers up to a maximum allowable charge of $2,000 per device at 50% copay ($1,000 maximum payable). A prescription from a doctor of medicine (M.D.) is required. The copay applies towards the ACA OOP maximum only. 23 Please have your provider contact the Fund s Utilization Administrator (Anthem Blue Cross) to facilitate your care through Case Management Intervention. On the backside of your Medical ID card, you will find the phone number for PreAuthorization or Pre-Service Review. 24 If the Wellness benefit maximum is exhausted, eligible wellness care expenses will be considered under the medical plan, subject to the annual deductible, medical necessity review and plan cost sharing requirements. (Doesn t apply to Low Option plan and Preventive Care 5 Service benefits).

7 OTHER MEDICAL SERVICES MEDICAL, MENTAL HEALTH AND CHEMICAL DEPENDENCY PPO PLAN LOW OPTION PLAN 1 PPO service area of 2 providers) 3, 4 Speech Therapy (subject to plan restrictions) 20 85% 100 visits/ calendar year 100 visits/ calendar year 80% 100 visits/ calendar year 100 visits/ calendar year 60% 100 visits/ calendar year Coordinated with speech therapy benefits provided through child s school. Any sessions covered through school program will reduce visits, on a one-for-one basis. Coordinated with speech therapy benefits provided through child s school. Any sessions covered through school program will reduce visits, on a one-for-one basis. Coordinated with speech therapy benefits provided through child s school. Any sessions covered through school program will reduce visits, on a one-for-one basis. Coordinated with speech therapy benefits provided through child s school. Any sessions covered through school program will reduce visits, on a one-for-one basis. Coordinated with speech therapy benefits provided through child s school. Any sessions covered through school program will reduce visits, on a one-for-one basis. Transplant Services 23 Required - 85% Required - Required - 80% Required - Required - 60% Treatment of TMJ Dysfunction 85% for X-rays and 6 physiotherapy visits for X-rays and 6 physiotherapy visits 80% for X-rays and 6 physiotherapy visits for X-rays and 6 physiotherapy visits 60% for X-rays and 6 physiotherapy visits Wellness Benefits 24 (Ages 7 and older; refer to SPD for covered services) $500/person or $1,500/family/ calendar year for specific wellness care expenses covered at 100% up to this limit $500/person or $1,500/family/ calendar year for specific wellness care expenses covered at 100% up to this limit $500/person or $1,500/family/ calendar year for specific wellness care expenses covered at 100% up to this limit IMPORTANT! Wellness and Preventive Care Services are not subject to a copay or annual deductible. 11 6

8 THE INDUSTRY HEALTH Participants can take advantage of significant savings available to you when you use The Industry Health Network (TIHN) available only in Southern California. UCLA Health operates five Motion Picture & Television Fund (MPTF) Health Centers in Los Angeles. These health centers are exclusive to entertainment industry members, and conveniently located near studios and other industry locations. Initially, you must choose a primary care physician (PCP). Your PCP will treat you directly, coordinate your care and, if necessary, refer you to a TIHN specialist. Without a PCP referral, your standard Writers' Guild-Industry Health Fund (WGIHF) benefits will apply, including your deductible and coinsurance. No enrollment is required to use this benefit. You can change your PCP at anytime as well as use other providers within The Industry Health Network. All TIHN benefits are subject to the maximums and limitations listed in this Summary of Benefits and your Summary Plan Description. All claims from a TIHN specialist must be submitted with the referral number assigned by MPTF. The Preventive Care services rendered under the TIHN network are not subject to a $10 copay and will not be applied towards your Wellness Benefit maximum. If the health center doctor treating you determines that a behavioral health provider should treat your condition, they will provide you with a medical order28 rather than a referral. At this time, behavioral health services will not be part of the TIHN referral program. Referral from a primary care physician (TIHN) does not guarantee payment. All services are subject to medical necessity. Subject to the maximums and limitations of the plan. PLAN BENEFITS WHEN YOU USE THE INDUSTRY HEALTH PCP Office Visit11 $10 copay Specialist Office Visit 25 $10 copay (Referrals to Specialists who will provide Alternative Medicine services, such as Physical/Occupational Therapy are subject to the Plan s Alternative Medicine $60 allowable per visit limitation. The patient is responsible for the amount in excess of the payable amount) Periodic Physical Exam11, 26 No copay Well Child Care/Pediatric Visit11, 27 $10 copay Lab Work/X-rays11, % Physical Therapy25 $10 copay Hospitalization17, % after $100 Surgery25 100% after $100 copay Anesthesiology25 100% (Subject to the Plan s Alternative Medicine $60 allowable per visit limitation) 25 Requires a written referral from your PCP. (This only applies to specialist charges.) 26 $200 is applied to your Wellness Benefit. Wellness Benefit for over age 7 only. 27 For children under the age of 13, the participant must call the UCLA Health/Motion Picture Televison Fund (MPTF) Customer Service Department at (800) for a referral to see a pediatric physician. 28 A medical order is a treatment recommendation that requires self-referral to a behavioral physician. 7

9 PHARMACY BENEFITS Participants and covered dependents will automatically be enrolled in the Pharmacy Program if you are enrolled in the PPO Plan only. The benefits are administered by Express Scripts. PPO PLAN LOW OPTION PLAN 1 NON- PPO service area of 2 providers) 3, 4 NON- 29, 27 PRESCRIPTION DRUGS Retail (up to a 30-day supply) Generic Preferred Brand Non-Preferred 31, 32 Brand $10 copay 33 $15 copay 33 $25 copay 33 $10 copay 30 $15 copay 30 $25 copay 30 $10 copay $15 copay $25 copay 33 Mail Order (up to a 90-day supply) 34 Generic Preferred Brand Non-Preferred 31, 32 Brand $20 copay 33 $30 copay 33 $36 copay 33 $20 copay 30 $30 copay 30 $36 copay 30 $20 copay $30 copay $36 copay 33 IMPORTANT! Compound medications will be subject to the preauthorization requirements. If any ingredient in a compound medication is on Express Scripts list of excluded ingredients, ESI will work closely with the compounding pharmacy to replace or remove the non-covered ingredient. Drugs on the ESI s Preferred Drug Exclusion List will not be covered by the Plan. Physicians may initiate the Formulary Exception Process by contacting ESI at (800) Subject to coordination of benefits provision. 30 You must pay the full cost of the drug at the point of purchase. You will be reimbursed according to the plan s schedule of benefits when you submit your claim to Express Scripts. 31 Brand-name copay applies only when doctor specifies Dispense As Written (DAW) on the prescription and no generic equivalent is available. For non-covered drugs, see Express Scripts website at 32 If generic equivalent is available, patient pays generic copay plus the cost difference between generic drug and brand-name drug even if the doctor specifies Dispense as Written (DAW) on the prescription. 33 Over-the-counter drugs allowed under the Preventive Care Service Benefits are administered by Express Scripts. See list of eligible preventive care benefits in the SPD. 34 Using the mail-order service is mandatory for maintenance medications. 8

10 VISION BENEFITS All eligible participants (excluding participants covered under the Low Option Plan) will automatically be enrolled in the vision program which is administered through Davis Vision. PPO PLAN PPO service area of 2 providers) 3, 4 LOW OPTION PLAN 1 PLAN BENEFITS Eye Examination $10 copay $50 allowance Eye Glasses Each Calendar Year Each Calendar Year (in lieu of contact lenses) Lenses Frames.$25 copay standard singlevision, lined bifocal, or trifocal 100% - Davis Vision Frames -or- $130 retail allowance, plus 20% off balance $50 Single Vision $65 Bifocal/ Progression $80 Trifocal $100 Lenticular $70 allowance Not applicable 11 Not applicable Not applicable Contact Lenses (in lieu of eye glasses) Each Calendar Year Each Calendar Year Not applicable Evaluation, Fitting & Follow-up Care Contacts: $25 copay Specialty: $60 allowance with 15% off balance less $25 copay Contact Lenses Covered in full Any contacts lenses from Davis Vision s Contact Lens Collections -or- $130 allowance toward provider supplied contact lenses, plus 15% off balance. Elective Contacts up to $105 Medical Necessary Contact up to $225 (Includes Evaluation, Fitting & Follow-up Care) Not applicable IMPORTANT! Vision benefits cannot be split between a network and out-of-network provider. Each calendar year, eye glasses or contact lens are covered under the vision care benefits and not both. For out-of-network providers you can obtain a claim form from our website at or on-line at Additional discounts not applicable at Walmart, Sam s Club and Costco locations. Check with Davis Vision if the eye provider at Walmart, Sam s Club or Costco is a contracted provider. 9

11 DENTAL BENEFITS Participants and covered dependents will automatically be enrolled in the Delta Preferred Option (DPO) if you are enrolled in the PPO Plan only. If you live in California, you may choose to enroll in the DeltaCare USA Dental HMO (DHMO), a managed dental plan, instead. You also have the option of enrolling your eligible dependent(s) in the DHMO. DELTA PREFERRED OPTION (DPO) DELTACARE DPO PROVIDER DELTA DENTAL PROVIDER (NOT PART OF DPO ) PROVIDER 35, 36 DHMO (APPLIES TO CALIFORNIA ONLY) PLAN FEATURES Calendar-Year Deductible Plan Maximum Diagnostic, Preventive, Basic and Major Services Orthodontia PLAN BENEFITS Diagnostic and Preventive Benefits $75/person or $150/family (doesn t apply to diagnostic and preventive services) $75/person or $150/family (doesn t apply to diagnostic and preventive services) $75/person or $150/family (doesn t apply to diagnostic and preventive services) $2,500/calendar year 37 $2,500/calendar year 37 $2,500/calendar year 37 Coverage for children up to the age 19 $2,000 Lifetime maximum 100% of DPOapproved fee (no deductible applies) Coverage for children up to the age 19 $2,000 Lifetime maximum 80% of Deltaapproved fee (no deductible applies) Coverage for children up to the age 19 $2,000 Lifetime maximum 80% of Delta-approved fee; you pay remaining 20% plus fees above approved amount None Unlimited (See Delta Dental s Evidence of Coverage 38 (EOC) Schedule A for a description of benefits and copayments) (See Delta Dental s Evidence of Coverage 38 (EOC) Schedule A for a description of benefits and copayments) Basic and Major Benefits 80% of DPO-approved fee of Delta-approved fee of Delta-approved fee; you pay remaining 30% plus fees above approved amount (See Delta Dental s Evidence of Coverage 38 (EOC) Schedule A for a description of benefits and copayments) IMPORTANT! The following benefits are covered under the Preventive Care Service benefits at 100%, with no deductible: - Fluoride supplements for children without fluoride in their local water supply. - Oral health risk assessment for young children Services received from a non-network dentist are not covered, except in an emergency if your DeltaCare dentist is unavailable or cannot see you within 24 hours of making contact or you believe your condition makes it dentally/medically inappropriate to travel to your contracted dentist to receive emergency services. 36 The plan will reimburse up to $100 of non-network emergency dental care per emergency, per enrollee, less any applicable copayment. 37 Plan maximum annual dollar limit does not apply to dependent children under the age of 19. Exception for Orthodontia Benefits will be limited to the lifetime maximum of $ You can obtain an EOC by contacting DeltaCare USA Customer Relations at (800)

12 DENTAL BENEFITS DELTA PREFERRED OPTION (DPO) DELTACARE DPO PROVIDER DELTA DENTAL PROVIDER (NOT PART OF DPO ) PROVIDER 37, 38 DHMO (APPLIES TO CALIFORNIA ONLY) PLAN BENEFITS Orthodontia Benefits of DPO-approved fee (Coverage for children up to age 19) 39 Benefits are limited to a $2000 lifetime maximum. 50% is payable at the time of banding and the remaining 50% twelve months later. of Delta-approved fee (Coverage for children up to age 19) 39 Benefits are limited to a $2000 lifetime maximum. 50% is payable at the time of banding and the remaining 50% twelve months later. of Delta-approved fee (Coverage for children up to age 19) 39 Benefits are limited to a $2000 lifetime maximum. 50% is payable at the time of banding and the remaining 50% twelve months later. Up to age 19: 100% after $350 start-up fee; $1,600 copay (for 24 months of standard orthodontia treatment; additional fee may apply after 24 months) Adults and dependents years of age: 100% after $350 start-up fee; $1,800 copay (for 24 months of standard orthodontia treatment; additional fee may apply after 24 months) Dental Work Performed by a Pedodontist 40 Percentage of approved fee varies based on type of service Percentage of approved fee varies based on type of service Percentage of approved fee varies based on type of service Pedodontic referrals must be pre-authorized by DeltaCare. Up to age 7: 100% less applicable co-payments following an attempt by the assigned contracted dentist to treat the child and upon prior authorization by DeltaCare USA. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis. 39 Up to age 19 with a $25 deductible. 40 A Pedodontist is a dentist who specializes in the growth and development of children s teeth. 11

13 IMPORTANT TELEPHONE NUMBERS AND WEBSITES FOR QUESTIONS CONTACT PHONE WEBSITE Eligibility, Claims, General Benefits, and Life and AD&D Insurance Writers Guild-Industry Health Fund 2900 W. Alameda Ave Suite 1100 Burbank, CA (818) or (800) PPO Plan and Low Option Plan Providers Physician and Hospital Network in California: Anthem Blue Cross of California (800) 810-BLUE (2583) Physician and Hospital Network Outside California: BlueCard Prescription Drug Benefits The Industry Health Network DPO Dental Plan DeltaCare Dental HMO Prescription Drug Network Nationwide: EXPRESS SCRIPTS UCLA Health/Motion Picture & Television Fund (MPTF) Customer Service Delta Preferred (DPO) Customer Relations DeltaCare USA Customer Relations (Available in California only) (800) (855) (800) (800) deltacareusa Vision Plan Davis Vision (800) TIHN HEALTH CENTERS LOCATIONS PHONE NUMBERS Bob Hope Health Center Los Angeles, Hollywood, Mid-City (323) Jack H. Skirball Health Center Woodland Hills (818) Santa Clarita Health Center Valencia (661) Toluca Lake Health Center Toluca Lake, Burbank (818) Westside Health Center Los Angeles, West Los Angeles (310)

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