Vision Program. Effective January 1, Introduction How the Program Works... 2

Transcription

1 Vision Program Effective January 1, 2011 Introduction... 2 How the Program Works... 2 A Snapshot of Your Vision Coverage Through Vision Service Plan (VSP)... 3 What the Program Covers... 3 Using VSP Network Providers... 3 Extra Discounts and Savings... 4 Using a Non-VSP Provider... 4 Optional Services... 5 Expenses Not Covered... 5 Applying for Benefits... 5 If Your Claim Is Denied Appeal Procedures... 6 Defective Claims... 6 Initial Claim Review... 6 Initial Benefit Determination... 6 Review of Initial Benefit Denial... 7 Review Procedures for Denials... 7 Statute of Limitations... 9 When Vision Coverage Ends Employee Spouse Child COBRA Continuation Coverage

2 Introduction As an optional part of the PCA Health Care Plan, vision coverage allows you and eligible family members to receive routine eye care. Annual eye exams for each enrolled person are covered, as are new eyeglasses or contact lenses. This coverage is for the maintenance of your visual accuracy. Treatment of diseases and injuries to the eye are discussed in the Medical Program. The vision coverage program is administered through Vision Service Plan (VSP). This company has developed a nationwide network of vision care professionals. You can choose to use this network by going to a network optometrist, or you can be reimbursed in part for getting your routine eye care from an optometrist who is not a member of the VSP network. If you use the network, covered services are prepaid with no deductible. If you use the services of an optometrist who is not a participant in the network, the program reimburses you for covered expenses according to a schedule of benefits. How the Program Works You decide if you are going to use a VSP network doctor or a non-vsp provider. However, dollar for dollar, you get the best value from your VSP benefit when you use a VSP network doctor. In addition, VSP network doctors also provide exceptional care and offer a wide selection of frames to choose from. If you decide not to see a VSP network doctor, copays still apply. You ll also receive a lesser benefit and typically pay more outof-pocket. Either way, below are the steps toward receiving benefits under this program. If You Use a VSP Network Doctor Call VSP to find a VSP network doctor close to your home or work at or sign on vsp.com. Make an appointment with a VSP doctor and tell the doctor you re a VSP member. Your doctor and VSP will handle the rest. The VSP network doctor will contact VSP directly to confirm your eligibility. Your doctor will submit the bills directly to VSP. You are responsible to pay for services your VSP plan does not cover in full. If You Use a Non-VSP Provider Make an appointment with any provider. Pay all costs at the time of your appointment and obtain an itemized receipt. Submit your itemized receipt listing the services received along with the patient s name and covered member s name and ID number to VSP. Out-of-network claims must be submitted to VSP within six months. Keep a copy of the claim and send the originals to: VSP, P.O. Box , Sacramento, CA , or sign on to vsp.com, select the Out-of-Network Reimbursement Form and follow the instructions. 2

3 A Snapshot of Your Vision Coverage Through VSP When you use a network doctor, the plan pays 100% of the cost of an annual routine eye exam and one pair of prescription glasses each year. A lower level of benefits applies when you use a non-vsp provider. Services for diseases and injury to the eye are subject to PCA Medical Program coverage. When you receive care from a VSP doctor, you don t need to file a claim form. Provision Coverage Categories Description Employee only; employee + spouse; employee + children; employee + family Vision Service Options VSP Network Doctor Non-VSP Provider Reimbursement Level Annual Routine Eye Exam 100% of covered expenses Up to $50 Prescription Glasses Contact Lenses Lenses: 100% for one set of single vision, lined bifocal, lined trifocal and polycarbonate lenses for children and handicapped dependents each year Frame: A frame of your choice covered up to $130, plus 20% off any out-ofpocket costs each year Medically necessary*: 100% for one set of contacts each year Elective contacts: $105 allowance for contact lens exam and contacts each year Single vision lenses: Up to $50 a pair Linded bifocal lenses: Up to $75 a pair Lined trifocal lenses: Up to $100 a pair Frames: Up to $70 each year Medically necessary*: $210 each year for one set of contacts, with VSP priorapproval Elective contacts: Up to $105 allowance for contact lens exam (fitting & evaluation) and contacts each year Claims Administrator *With prior approval from VSP for medically necessary contacts. What the Program Covers Through VSP s network, private-practice optometrists and ophthalmologists agree to perform services for predetermined fees. If you use a non-vsp provider, the program pays a portion of the costs based on VSP s schedule of fees for certain covered services. Using VSP Network Doctors If you choose treatment by a VSP doctor, the program pays: 100% for an annual routine eye exam. 100% each year for lenses. This includes single vision, lined bifocal and lined trifocal lenses as well as tinted and photochromic lenses. The plan does not cover options chosen for cosmetic reasons. Patients should check with their VSP doctor to verify covered items. VSP 3

4 100% each year for select covered frames. The program includes a wide choice of frames. When deciding on a frame, ask your VSP doctor which frames are covered in full. You may choose a frame outside the plan coverage and pay the difference. 100% each year for contact lenses medically necessary. You must get prior approval from VSP for medically necessary contacts. $105 total for the contact lens exam and contact lenses that are not medically necessary (i.e., medically necessary means your vision cannot be corrected with glasses). If you elect to receive contacts, any glasses you also purchase will not be covered under the plan that calendar year. Extra Discounts and Savings Laser vision correction discounts You ll receive up to 30% savings on lens extras such as scratch resistant and anti-reflective coatings and progressives You ll receive a 20% discount on a second pair of glasses, and sunglasses, including non-prescription Contacts*: You receive 15% discount off the cost of your contact lens exam (fitting and evaluation) *Available from the same VSP network doctor who provided your eye exam within the last 12 months Using a Non-VSP Provider Instead of going to a VSP network doctor, you can be treated by the licensed optometrist, ophthalmologist or eye specialist of your choice. When you purchase glasses or contact lenses, you pay the full cost. You then apply for partial reimbursement from the program. Each calendar year, the program pays for you and each covered family member: Up to $50 for an annual routine eye exam. Up to: $50 a pair * for single vision lenses. $75 a pair * for lined bifocal lenses. $100 a pair * for lined trifocal lenses. Up to $70 for a frame. Up to $210 a pair for medically necessary contact lenses. VSP must approve the medical necessity of contact lenses before you can receive reimbursement for them. If your vision can be corrected with glasses but you still elect to purchase contact lenses, the program will pay $105 toward the cost of your eye exam and elective contact lenses. This benefit is the same regardless of whether you obtain the contact lenses from a VSP network doctor or not. * The above lens allowances are based on two lenses. If only one lens is obtained, the allowance will be one half of the amount shown. 4

5 Optional Services The vision program is designed to provide you with necessary eye care and corrective eyeglasses. If you want to purchase certain optional services, you can buy these extras for additional cost controlled by VSP. Your VSP optometrist can tell you whether something is covered by the program or is considered an option. Examples of options for which you pay extra include the following: Blended lenses; Oversize lenses; Progressive multifocal lenses, e.g., progressive bifocals; Coated or laminated lenses; Frames costing more than the program allowance; Certain costs for low vision care; Cosmetic lenses (lenses for eyeglasses that serve no corrective vision purpose); Ultraviolet-protected lenses; and Optional cosmetic processes. Expenses Not Covered The vision program does not pay any benefits for: Orthoptics or vision training and any associated supplemental testing. Plano lenses (non-correcting or non-prescription). Two pairs of glasses instead of bifocals. Medical or surgical treatment for the eyes. (This may be covered by the PCA Health Care Plan medical coverage, if you are enrolled in that program.) Any eye examination or corrective eyewear required by an employer as a condition of employment. Lost, stolen, or broken eyeglasses or contact lenses. More than one pair of eyeglasses or contact lenses during the calendar year. Applying for Benefits A VSP network optometrist receives payment directly from VSP for covered expenses. If you are not using a VSP optometrist, you submit your itemized bill with the claim number to VSP. You are then reimbursed as shown on the schedule in the section entitled What the Program Covers on page 4. 5

6 If Your Claim Is Denied Appeal Procedures Defective Claims In the case of your failure to follow the Plan's procedures for filing a proper claim, the Claims Administrator will notify you of the failure and the proper procedures to be followed in filing a claim. The Claims Administrator will provide notice to you as soon as possible but in the case of a claim requiring prior authorization, the notice will be provided within five (5) days of receipt of the claim by the Claims Administrator. In the case of a failure to follow the proper procedures with respect to a claim involving urgent care, the notice will be provided to you within 24 hours of such receipt. Initial Claim Review The initial claim review will be conducted by the Claims Administrator, who will consider the applicable terms and provisions of the Plan and amendments to the Plan, information and evidence that is presented by you and any other information it deems relevant. Initial Benefit Determination Claim Involving Urgent Care. In the case of a claim involving urgent care, the Claims Administrator will notify you of the benefit determination (whether adverse or not) no later than 72 hours after receipt of the claim by the Claims Administrator, provided that you provide sufficient information to determine whether, and to what extent benefits are payable under the Plan. In the case of your failure to provide sufficient information to determine whether and to what extent a claim involving urgent care is covered by the Plan, the Claims Administrator will notify you within 24 hours after receipt of the claim, of the specific information necessary to complete the claim. You will be afforded a reasonable amount of time, taking into account the circumstances but in no event less than 48 hours, to provide the specified information. The Claims Administrator will notify you of the benefit determination no later than 48 hours following the earlier of (1) the Claims Administrator's receipt of the specified information or (2) the end of the period afforded you to provide the specified additional information. Concurrent Care Decision. In the case of a denial of coverage involving a course of treatment (other than by amendment or termination of the Plan) before the end of such period of time or number of treatments, the Claims Administrator will notify you of such denial at a time sufficiently in advance of the reduction or termination to allow you to appeal and obtain a determination on review of that denial before the benefit is reduced or terminated. Where you want to extend the course of treatment beyond the period of time or number of treatments and it is a claim involving urgent care, the Claims Administrator will notify you of the benefit determination, whether adverse or not, within 24 hours after receipt of the claim by the Claims Administrator (provided that any such claim is made to the Claims Administrator at least 24 hours prior to the expiration of the prescribed period of time or number of treatments). Pre-Service Claim. In the case of a claim involving prior authorization, the Claims Administrator will notify you of the benefit determination (whether adverse or not) within 15 days after receipt of the claim. The Claims Administrator may extend the period for making the benefit determination by 15 days if it determines that such an extension is due to matters beyond the control of the Plan and if it notifies you, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which the Claims Administrator expects to render a decision. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information, you will be afforded at least 45 days from receipt of the notice within which to provide the specified information, and the period in which the Claims Administrator is required to make a decision will be suspended from the date on which the notification is sent to you until you adequately respond to the request for additional information. 6

7 Post-Service Claim. In the case of a claim filed after the medical care has been delivered, the Claims Administrator will notify you of the denial within 30 days after receipt of the claim. The Claims Administrator may extend the period for making the benefit determination by 15 days if it determines that such an extension is due to matters beyond the control of the Plan and if it notifies you, prior to the expiration of the initial 30- day period, of the circumstances requiring the extension of time and the date by which the Claims Administrator expects to render a decision. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information, you will be afforded at least 45 days from receipt of the Notice within which to provide the specified information, and the period in which the Claims Administrator is required to make a decision will be suspended from the date on which the notification is sent to you until you adequately respond to the request for additional information. Manner and Content of Notification of Denied Claim. The Claims Administrator will provide you with written or electronic notice of any denial, in accordance with applicable Department of Labor regulations. The notification will set forth: the specific reason or reasons for the denial; reference to the specific provision(s) of the Plan on which the determination is based; a description of any additional material or information necessary for you to perfect the claim and an explanation of why such material or information is necessary; if an internal rule, guideline, protocol or other similar criterion was relied upon in making the denial, the notice will either (1) set forth such specific rule, guideline, protocol or other similar criterion of the Plan that was relied upon or (2) provide a statement that such rule, guideline, protocol or similar criterion was relied upon, and that a copy will be provided free of charge to you upon request; if the denial is based on a medical necessity or experimental treatment or similar exclusion or limit, the notice will provide either (1) an explanation of the scientific or clinical judgment relied upon for the determination or (2) a statement that such explanation will be provided free of charge upon request; a description of the Plan's review procedures and the time limits applicable to such procedures, and if a claim involving urgent care, of the expedited review process; and the following statement: You and your plan may have other voluntary dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state regulatory agency. Review Of Initial Benefit Denial Procedure for Filing a Review of a Denial. Any appeal of a denial by you must be brought to the Plan Administrator within 180 days after receipt of the notice of denial. Failure to appeal within such 180-day period will be deemed to be a failure to exhaust all administrative remedies under the Plan. The appeal must be in writing utilizing the appropriate form provided by the Plan Administrator (or in such other manner acceptable to the Plan Administrator), provided, however, that if the Plan Administrator does not provide the appropriate form, no particular form is required to be utilized by you. The appeal must be filed with the Plan Administrator at the address listed in the Summary Plan Description. Review Procedures for Denials The Plan Administrator will provide a review that takes into account all comments, documents, records and other information submitted by you without regard to whether such information was submitted or considered in the initial benefit determination; You will have the opportunity to submit written comments, documents, records and other information relating to the claim; 7

8 You will be provided, upon request and free of charge, reasonable access to and copies of all relevant documents; The review procedure will not require more than two levels of appeals of a denial; The review of a denial will not afford deference to the initial determination made by the Plan Administrator; The individual who will conduct the review process will not be the individual who made the initial denial nor the subordinate of such individual; In deciding an appeal of any denial that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug or other item is experimental, investigational or not medically necessary or appropriate, the Plan Administrator will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The health care professional will be an individual who was neither consulted in connection with the denial nor the subordinate of any such individual; The Plan Administrator will identify any medical or vocational experts whose advice was obtained on behalf of the Plan in connection with your denial, without regard as to whether the advice was relied upon in making the benefit determination; and In the case of a claim involving urgent care, an expedited review process will be provided. You may request an expedited appeal orally or in writing and all necessary information may be transmitted between the Plan and you by telephone, facsimile, or other available similarly expeditious method. Timing of Notification of Benefit Determination on Review. Claim Involving Urgent Care. In the case of a claim involving urgent care, the Plan Administrator will notify you of the benefit determination on review within 72 hours after receipt of your request for review. Pre-Service Claim. The Plan Administrator will notify you of the benefit determination on review within 30 days after receipt of the request for review. Post-Service Claim. The Plan Administrator will notify you of the benefit determination on review within 30 days after receipt of the request for review. Manner and Content of Notification of Benefit Determination on Review. The Plan Administrator will provide a written or electronic notice of the Plan s benefit determination on review, in accordance with applicable Department of Labor regulations. The notification will set forth: The specific reason or reasons for the denial; Reference to the specific provision(s) of the Plan on which the determination is based; A statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of all relevant documents; If an internal rule, guideline, protocol or other similar criterion was relied upon in making the denial, the notice will either (1) set forth such specific rule, guideline, protocol or other similar criterion of the Plan that was relied upon or (2) provide a statement that such rule, guideline, protocol or similar criterion was relied upon, and that a copy will be provided free of charge to you upon request; If the denial is based on a medical necessity or experimental treatment or similar exclusion or limit, either (A) an explanation of the scientific or clinical judgment relied upon for the determination or (B) a statement that such explanation will be provided free of charge upon request; and 8

9 The following statement: You and your plan may have other voluntary dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state regulatory agency. External Review. To the extent required by applicable law, or to the extent provided by this Plan, you may pursue voluntary levels of appeal or dispute resolution in addition to those provided herein. Failure to pursue a voluntary level of appeal will not constitute failure to exhaust this claims and appeals procedure, all defenses of the Plan based on timeliness will be tolled during the voluntary appeal, and the voluntary appeal may only be pursued after the claims and appeals procedure set forth herein has been complied with by you in it entirety. The Plan provides one level of voluntary appeal in addition to those set forth above. If your claim is denied on appeal, you may request within 60 days of the mailing of the denial that the Plan Administrator review your situation an additional time by complying with the appeal process and submitting any additional documentation to the Plan Administrator for the Plan Administrator to review. If you choose not to pursue this voluntary level of appeal, you may proceed directly to Court. The Plan Administrator s decision on review shall be made within such time frames as set forth under the mandatory appeals process above. Statute Of Limitations No cause of action may be brought by you after you have received a final denial later than one year following the mailing date of such final denial. 9

10 When Vision Coverage Ends Employee The following chart shows when vision coverage ends in certain instances. Employment Status Coverage Ends Termination Death Total Disability (LTD) Non-FMLA Approved Personal Leave of Absence (Unpaid) FMLA Approved Leave of Absence (Unpaid) Disability Non-Occupational Leave of Absence (Paid or Unpaid) Worker s Comp Leave of Absence (Paid or Unpaid) Military Leave of Absence (Paid) Military Leave of Absence (Unpaid) Layoff The date the program is amended or terminated. PCA, the Plan sponsor, reserves the right to terminate the medical program or amend the program in such a manner that you may no longer be eligible to participate in the program; your employer may cease being a Participating Employer or the level of benefits available may be reduced. End of month End of second month following (The company pays the full cost of this continued coverage) End of month End of month Continues up to a maximum of 12 weeks (You pay the same contribution that active employees pay) Continues up to a maximum of 26 weeks (You pay the same contribution that active employees pay) Continues up to a maximum of 26 weeks (You pay the same contribution that active employees pay) Continues up to a maximum of 30 days (You pay the same contribution that active employee pay) End of third month following End of month End of month Important: An amendment or termination of the PCA Health Care Plan medical coverage program may affect not only the coverages of active employees (and their covered dependents) but also of COBRA participants and former employees who retired, died or otherwise terminated employment. Spouse Coverage for your spouse will end the last day of the month in which the earliest of the following occurs: The date your coverage ends; The date the marriage is legally dissolved; The date your spouse is no longer enrolled for coverage; or The date your spouse enters the armed forces. 10

11 Child Coverage for your child will end the last day of the month in which the earliest of the following occurs: The date your coverage ends; The date your child is no longer eligible for coverage; The date your child is no longer enrolled for coverage; or The date your child enters the armed forces. If a covered person is hospitalized the day coverage ends or is reduced, full benefits for the hospitalized patient will continue until he or she is released. COBRA Continuation Coverage If your coverage ends, you and your enrolled dependents may be eligible for continued coverage through a federal law known as COBRA. This is described in the section on COBRA in the Health & Welfare Benefits Overview section of this Benefits Handbook. 11