MEDICAL ASSISTANCE FUND

Transcription

1 Medical Assistance Fund Fact Sheet MEDICAL ASSISTANCE FUND Eligibility The Medical Assistance Fund is intended to help offset increased out-of-pocket costs for benefits-eligible faculty and administrators who experience financial hardship as a result of the elimination of the option or transition from the EPO option to the Standard plan option effective January 1, Plan Details s approved under the Medical Assistance Fund will be issued after the close of the plan year. The Medical Assistance Fund is funded by Fordham University and unused funds will carry over from one plan year to the next until December 31, The Medical Assistance Fund is funded by a flat dollar amount each year. If the dollar amount of total eligible claims exceeds the funding level for any given year, the claims will be paid on a pro rata basis. Debit Card The Discovery Benefits debit card is not tied to the Medical Assistance Fund. Individuals enrolled in a Flexible Spending Account (FSA) or Health Arrangement (HRA) can continue to use the debit card for eligible expenses at the point of transaction. Requests To request reimbursement from the Fund, submit a copy of the Explanation of Benefits (EOB) from UnitedHealthcare and a completed Out-of-Pocket Request Form to Discovery Benefits. Options for submitting the EOB(s), along with the attached Out-of-Pocket Request form, include mail, , or fax. Your online account and mobile app will provide details on submitted claims. Note: Discovery Benefits contact information is listed below and on the Out-of-Pocket Request Form. The fund has a threshold that you will need to meet before applications for reimbursement can be considered. Eligible expenses should be submitted to Discovery Benefits to satisfy the threshold requirements. (See the following page to determine your threshold amount.) Payment Options Direct Deposit To enroll in free direct deposit, simply log in to your Discovery Benefits online account and enter your bank account information. Check If Discovery Benefits doesn t have your direct deposit information on file, a check will be sent to your mailing address. Note: All forms of payments will be issued after the close of the plan year following reconciliation and approval. Contact Discovery Benefits You can get in touch with our Participant Services team by calling our toll-free number at , submitting a toll-free fax to , sending an to customerservice@discoverybenefits.com or sending by mail to: Discovery Benefits PO Box 2926 Fargo, ND

2 Medical Assistance Fund Fact Sheet, continued The following information is meant to provide a general summary about the design of the Medical Assistance Fund. However, please note that the information contained within this document is merely provided as a reference and is not intended to serve as a formal contract. Medical Assistance Fund Threshold Information Your plan a threshold in place. has does not have Your threshold amounts for spending in 2018 are: Single: $ Family: $ Eligible Expenses Your Medical Assistance Fund eligible expenses are the out-of-pocket medical expenses (copay, deductible and co-insurance) that exceed the threshold amounts listed and that were paid by the employee or an eligible dependent. The amounts to be reimbursed are outlined in the attached Claim Processing Guidelines. Additional Notes About Your Plan The Medical Assistance Fund will operate independently from the Fordham University FSA and HRA plans. Please note that the administration of your existing FSA and HRA plans won t change. To access the Medical Assistance Fund, individuals will need to submit claims to this plan with the following information: 1. The full Explanation of Benefits, including the Summary Box from UnitedHealthcare. 2. A completed Discovery Benefits Out-of-Pocket Request Form. Revised 08/13/18

3 PO Box 2926 Fargo, ND Medical Assistance Fund Out-of-Pocket Request Form This form is not for Discovery Benefits Debit Card claims. This form is not for your HRA/FSA or HSA/Limited FSA requests for reimbursement under the Healthcare Spending Account Program. Step 1: Participant Information Complete the required fields (*). Please write legibly or type in the fields. Missing information may delay the processing of your claim. Step 2: Medical Information You may submit one form per EOB or attach all EOBs together and submit only one form. Note: Submitting one EOB per form is the preferred method. If you choose to attach all EOBs together, please input various under the Date of service(s), Provider Name(s), and Person(s) receiving the product or service fields below. Plan type: Medical Assistance Fund (MAF). Date of service(s): Provide the date or range of dates the expense was incurred, including the year. Provider name: Provide the name of the provider or facility where the expense was incurred. If filing multiple claims that include more than one provider, please write Multiple in this box. Person receiving the product or service: Provide your name or the name of the eligible dependent for which the service was provided or the product was purchased. If filing multiple claims for more than one covered member, please write Multiple in this box. Description of services: Provide a brief description of the service. Step 3: Participant Certification Submit the completed form with supporting documentation to Discovery Benefits. Mail: PO Box 2926; Fargo, ND Fax: Documentation Requirements Documentation for eligible medical expenses: Explanation of Benefits (EOB) from UnitedHealthcare Unacceptable forms of documentation include the following: Provider statements that indicate only the amount paid, balance forward or previous balance Credit card receipts that reflect only a payment

4 Out-of-Pocket Request Form, continued *Required Fields Step 1: Participant Information *Participant Name (First, MI, Last) *Social Security Number - - *Employer Name (Do not abbreviate) Employee ID Updates or changes to some of your information can be made by logging into your account at Step 2: Medical Information You may submit one form per EOB or attach all EOBs together and submit only one form. Note: Submitting one EOB per form is the preferred method. If you choose to attach all EOBs together, please input various under the Date of service(s), Provider Name(s), and Person(s) receiving the product or service fields below. (internal: this is a Claims request) *Plan Type *Date of Service *Provider Name *Person receiving the product or service Description of the services *Plan Types: MAF Medical Assistance Fund Step 3: Participant Certification To the best of my knowledge, the provided information is complete and accurate. I certify that the requests I am submitting are eligible expenses as defined by the IRS and that I have not been previously reimbursed by UnitedHealthcare for these expenses. I understand that Discovery Benefits, including its agents and employees, will not be held liable if I submit ineligible expenses for reimbursement. If there are any changes in the provided information, I understand it is my responsibility to notify Discovery Benefits. By submitting this form I certify the above. Pursuant to the terms of the plan, benefit payments that are not timely claimed may be forfeited back to the plan. I understand that I should retain a copy of all submitted documentation in the event of an IRS audit. *F001* Revised 08/13/18

5 CLAIMS PROCESSING GUIDELINES If you transitioned from Option to Standard Plan In Network Out of Network Plan 2017 Standard Plan Eligible For (after reaching threshold) Ref Plan 2017 Standard Plan 2018 Eligible For (after reaching threshold) Ref Office visit $ 10 $ 25 $ 15 1(a) Ded. & Coins. Ded. & Coins. Specialist (incl mental health outpatient) Inpatient hospital (incl mental health inpatient) $ 10 $ 50 $ 40 1(a) Ded. & Coins. Ded. & Coins. $ 0 $ 250 $ 250 1(a) Ded. & Coins. Ded. & Coins. Outpatient radiology $ 0 $ 250 $ 250 1(a) Ded. & Coins. Ded. & Coins. varies see notes 1(b) and (c) above varies see notes 1(b) and (c) above varies see notes 1(b) and (c) above varies see notes 1(b) and (c) above Emergency room $ 35 $ 100 $ 65 1(a) $ 35 $ 100 $ 65 1(a) Retail prescriptions: Tier 1 $ 5 $ 10 $ 5 1(a) $ 5 $ 10 $ 5 1(a) Tier 2 $ 15 $ 25 $ 10 1(a) $ 15 $ 25 $ 10 1(a) 1(b), 1(c) 1(b), 1(c) 1(b), 1(c) 1(b), 1(c)

6 In Network CLAIMS PROCESSING GUIDELINES CONT. If you transitioned from Option to Standard Plan Out of Network Tier 3 $ 25 $ 50 $ 25 1(a) $ 25 $ 50 $ 25 1(a) Mail Order prescriptions Tier 1 $ 10 $ 20 $ 10 1(a) $ 10 $ 20 $ 10 1(a) Tier 2 $ 30 $ 50 $ 20 1(a) $ 30 $ 50 $ 20 1(a) Tier 3 $ 50 $ 100 $ 50 1(a) $ 50 $ 100 $ 50 1(a) Deductible Individual $ 0 $ 250 $ 250 1(b) $ 200 $ 300 $ 100 1(b) Family $ 0 $ 500 $ 500 1(b) $ 400 $ 600 $ 200 1(b) Out of Pocket maximum Individual $ 2,500 $ 2,500 $ 0 1(b) $ 1,000 $ 2,500 $ 1,500 1(b), 2 Family $ 5,000 $ 5,000 $ 0 1(b) $ 2,000 $ 5,000 $ 3,000 1(b), 2 Coinsurance 0% 5% 5% 1(c) 20% 20% See note 2 1(c), 2

7 CLAIMS PROCESSING GUIDELINES If you transitioned from EPO Option to Standard Plan In Network Out of Network Office visit Specialist (incl mental health outpatient) Inpatient hospital (incl mental health inpatient) Outpatient radiology Emergency room EPO Option 2017 Standard Plan Eligible for (after reaching threshold) Ref EPO Option 2017 Standard Plan 2018 Eligible for (after reaching threshold) $ 0 $ 25 $ 25 1(a) Not available Ded. & Coins. $ 0 3 $ 2 $ 50 $ 48 1(a) Not available Ded. & Coins. $ 0 3 $ 0 $ 250 $ 250 1(a) Not available Ded. & Coins. $ 0 3 $ 0 $ 250 $ 250 1(a) Not available Ded. & Coins. $ 0 3 $ 15 $ 100 $ 85 1(a) Not available $ 100 $ 0 3 Ref Retail prescriptions: Tier 1 $ 5 $ 10 $ 5 1(a) Not available $ 10 $ 0 3 Tier 2 $ 5 $ 25 $ 20 1(a) Not available $ 25 $ 0 3 Tier 3 $ 5 $ 50 $ 45 1(a) Not available $ 50 $ 0 3 Mail Order prescriptions Tier 1 $ 10 $ 20 $ 10 1(a) Not available $ 20 $ 0 3 Tier 2 $ 10 $ 50 $ 40 1(a) Not available $ 50 $ 0 3 Tier 3 $ 10 $ 100 $ 90 1(a) Not available $ 100 $ 0 3 Deductible Individual $ 0 $ 250 $ 250 1(b) Not available $ 300 $ 0 3 Family $ 0 $ 500 $ 500 1(b) Not available $ 600 $ 0 3

8 CLAIMS PROCESSING GUIDELINES CONT. If you transitioned from EPO Option to Standard Plan In Network Out of Network Out of Pocket maximum Individual $ 2,500 $ 2,500 $ 0 1(b) Not available $ 2,500 $ 0 3 Family $ 5,000 $ 5,000 $ 0 1(b) Not available $ 5,000 $ 0 3 Coinsurance 0% 5% 5% 1(c) 20% 20% 0% 3

9 FOOTNOTES from the Medical Assistance Fund (the Fund) will be based on how the related services were billed, as follows: 1. All required minimum spending must be reached before an eligible employee may participate in the Fund. Thereafter, the following guidelines apply to reimbursement eligibility: a) For services billed as co-pays: The difference between the co-pay under the new and old options. b) For services billed (in whole or in part) to a deductible: the difference between the new and old options. c) For services billed as co-insurance: The difference between the new and old co-insurance. i. In some cases, b) and c) may be billed together for a single service. However, the amounts billed toward deductible and coinsurance must be evaluated separately in considering the amounts eligible for reimbursement. ii. The amount reimbursed as co-insurance is limited to the applicable out-of-pocket maximum. 2. for out-of-network services for an employee who had the option in 2017 and who is enrolled in 2018 in the Standard option will be made as follows: a. Since there is no difference in coinsurance (20%) between 2017 and 2018 for out-of-network services there will be no reimbursement payable to an eligible employee if the 2017 out-of-pocket maximum ($1,000 single/$2,000 family) is not exceeded. b. The Fund will reimburse in full, if eligible, the 20% coinsurance the participant pays in covered charges in excess of the 2017 outof-pocket limits up to the 2018 out-of-pocket limits ($2,500/$5,000). Once the 2018 out-of-pocket limit is reached, the UnitedHealthcare medical plan will cover 100% of Reasonable & Customary covered charges. 3. If an employee was formerly enrolled in the EPO option in 2017, is enrolled in the Standard option in 2018 and is now receiving out-of-network services in 2018, the employee will not receive reimbursement from the Fund for those expenses, since the EPO option did not offer out-of-network coverage in 2017.