Fort Worth Firefighters Healthcare Trust 2019 Benefits Guide

Transcription

1 Fort Worth Firefighters Healthcare Trust 2019 Benefits Guide

2 What s Inside The Local 440 Benefits Trust provides participants and their eligible dependents a vital program of benefits designed to keep you healthy, protect your financial security, and help you balance your life at work and home. Open enrollment is the time for you to review the coverage that will be offered by the Trust beginning January 1 st, 2019 and elect the benefits that will best meet the needs of you and your family during the coming year. This guide highlights your benefits. Official plan and insurance documents govern your rights and benefits under each plan. For more details about your benefits, including covered expenses, exclusions, and limitations, please refer to the individual Summary Plan Description (SPD), plan document, or certificate of coverage for each plan, which can be found in our company s designated office. If any discrepancy exists between this guide and the official documents, the official documents will prevail. X Healthcare Definitions X Changing Your Benefits X Your Health Plan X Health Program Costs for 2019 X How Your Plan Works X Maestro Administrators X Teladoc X Your Prescription Plan X AMPS A new added Benefit to your plan X LBG Advisors X Local 440 Benefits Information Website X Required Notices

3 Healthcare Definitions Fort Worth Fire 2019 Benefits 3 No Network Coverage extends to any licensed provider in the United States. Our plans are designed to give you the freedom to use the healthcare provider of your choice. Preventive Care Services These are services that are generally linked to routine wellness exams and screenings. Non-preventive services are those that are considered treatment or diagnosis for an illness, injury, or other medical condition. Preventive care is covered at 100% in-network. Annual Deductible The amount of money you must first pay out of pocket before your plan begins paying for services covered by coinsurance is your Annual Deductible. After you meet your deductible, the plan pays for a percentage of eligible expenses (coinsurance) until you meet your out-of-pocket maximum. Copayments and Coinsurance A copayment (or copay) is the fixed dollar amount you pay at the time of service. In some cases, you may be responsible for coinsurance after the copay is made. Coinsurance is the percentage of covered expenses shared by you and the plan. In some cases, coinsurance is paid after you meet a deductible. For example, the Basic Plan pays 85% of the covered charge after your Annual Deductible (if applicable). You are responsible for paying the remaining 15% coinsurance and any of the deductible that may apply to the claim. Maximum Out of Pocket Amount Your plan provides a stated maximum annual cost for you and your covered dependents. It includes amounts your pay for your deductible, coinsurance, pharmacy and co-payments. Once you reach this limit, your plan covers 100% of your eligible claims expenses for the rest of the year.

4 Healthcare Definitions continued Fort Worth Fire 2019 Benefits 4 Summary Plan Description (SPD) The SPD is an important document that defines the terms and care offered by the medical plan. The booklet describes who is eligible and when coverage terminates. It offers definitions for important terminology found within the contract to help you better understand the coverage afforded by the plan design. The Summary Plan Description also provides a list of specifically excluded services, procedures and conditions as well as describing your rights to appeal decisions that you disagree with. Health Plans are legally obligated by The Employee Retirement Income Security Act (ERISA) to provide participants SPDs for each benefit plan offered by the health plan.

5 Changing Your Benefits Fort Worth Fire 2019 Benefits 5 Certain Qualified Life Events (QLEs) may enable you to change your benefit elections at a time other than during open enrollment. You can change your benefit elections during the year if you experience a qualified life event. QLEs include: Marriage Divorce, annulment, or legal separation Birth of your child Death of your spouse or dependent child Adoption of/placement for adoption of your child Termination or commencement of your spouse s employment Change of employment status by you or your spouse, or another dependent Entitlement to Medicare or Medicaid Dependent satisfies or ceases to satisfy eligibility requirements Commencement of or return from an unpaid leave of absence A change in the place of residence of you, your spouse, or your dependent Your dependent satisfies or ceases to satisfy eligibility requirements A significant change in your or your spouse s health coverage due to your spouse s employment Qualification by the Plan Administrator of a Medical Child Support Order

6 Your Health Plan Basic Plan Fort Worth Fire 2019 Benefits 6 Covered Benefit Annual Deductible Annual Out-of-Pocket (Includes deductible) Preventative Care Periodic Health Exam: routine exam, well child care office visit, immunizations, routine lab and x-rays, routine prostate test, routine pap test, routine mammogram, etc.) Physician Office Visits Primary Care Office Visit (includes diagnostic lab & x-ray's) Specialty Care Office Visit (includes diagnostic lab & x-ray's) Maternity - Prenatal Maternity - Delivery What You Pay* $950 Single / $1,900 Family $5,000 Single / $6,000 Family There is no network for Primary Care or Specialists visits. All charges are subject to the reference-based reimbursement arrangement. Your responsibility is the appropriate Copay where applicable. No Charge when meeting federal Preventive Care guidelines $25 Copay / Visit $35 Copay / Visit $25 Copay / Initial Visit Only Other Services Urgent Care Facility Chiropractic Care Emergency Medical Transport Durable Medical Equipment Home Health Care Habilitation Services: Physical Therapy, Occupational Therapy & Speech Therapy Hospice $60 Copay / Visit $55 Copay / Visit 24 Visits per Calendar Year 1 visit/treatment per day 60 Visits Maximum Per Calendar Year $35 Copay / Visit 60 Visits Maximum Per Calendar Year 360 Days Maximum Per Lifetime

7 Your Health Plan Basic Plan continued Fort Worth Fire 2019 Benefits 7 Hospital Facility Services What you Pay Inpatient Surgery Room & Board Outpatient Surgery Diagnostic Laboratory / X-Rays MRI, PET Scan, CT Scan Emergency Room Services Miscellaneous Hospital Charges (Inpatient and Outpatient) Mental and Nervous / Substance Abuse Care (Inpatient and Outpatient) $250 Copay / Waived if Admitted $35 Copay / Visit Outpatient Prescription Drugs Generic Retail: $10.00 Copay / Mail Order: $25.00 Preferred Brand Retail: $30.00 Copay / Mail Order: $75.00 Non-Preferred Brand Retail: $50.00 Copay / Mail Order: $ Specialty Telephone Physician Consultations Teladoc All calls are $0 *Please note that certain services will require Pre-certification. Please refer to the SPD for additional information. **This summary is for illustrative purposes only. Your Summary Plan Description will supersede any comparison with this document.

8 Your Health Plan Consumer Choice HSA Plan Fort Worth Fire 2019 Benefits 8 Covered Benefit Annual Deductible Annual Out-of-Pocket (Includes deductible) Preventative Care Periodic Health Exam: routine exam, well child care office visit, immunizations, routine lab and x-rays, routine prostate test, routine pap test, routine mammogram, etc.) Physician Office Visits Primary Care Office Visit (includes diagnostic lab & x-ray's) Specialty Care Office Visit (includes diagnostic lab & x-ray's) Maternity - Prenatal Maternity - Delivery What You Pay* $1,500 Single / $3,000 Family $6,250 Single / $10,125 Family There is no network for Primary Care or Specialists visits. All charges are subject to the reference-based reimbursement arrangement. Your responsibility is the appropriate Copay where applicable. No Charge when meeting federal Preventive Care guidelines Other Services Urgent Care Facility Chiropractic Care Emergency Medical Transport Durable Medical Equipment Home Health Care Habilitation Services: Physical Therapy, Occupational Therapy & Speech Therapy Hospice 24 Visits per Calendar Year 1 visit/treatment per day 60 Visits Maximum Per Calendar Year 60 Visits Maximum Per Calendar Year 360 Days Maximum Per Lifetime

9 Your Health Plan Consumer Choice HSA Plan continued Fort Worth Fire 2019 Benefits 9 Hospital Facility Services What you Pay Inpatient Surgery Room & Board Outpatient Surgery Diagnostic Laboratory / X-Rays MRI, PET Scan, CT Scan Emergency Room Services Miscellaneous Hospital Charges (Inpatient and Outpatient) Mental and Nervous / Substance Abuse Care (Inpatient and Outpatient) Prescription Drugs Generic Preferred Brand Non-Preferred Brand Specialty Retail: / Mail Order: Retail: / Mail Order: Retail: / Mail Order: Telephone Physician Consultations Teladoc All calls are $40 *Please note that certain services will require Pre-certification. Please refer to the SPD for additional information. **This summary is for illustrative purposes only. Your Summary Plan Description will supersede any comparison with this document.

10 Teladoc Fort Worth Fire 2019 Benefits 10 Teladoc Customer Service: Teladoc The first and largest provider of telehealth medical consults in the United States, giving you 24/7/365 access to quality medical care through phone and video consults. How it Works Step 1: Contact Teladoc 24/7/365 Step 2: Talk with a Physician Step 3: Resolve the Issue For more information, go to the Teladoc tab on your Employee Benefits Website:

11 Health Program Costs for 2019 Fort Worth Fire 2019 Benefits 11 Medical Plan Cost Only Basic and Consumer Choice HSA Plans NOTE: Active Firefighter Costs shown on per PAYCHECK basis. Retiree costs are shown as MONTHLY amounts. EE EE&SP EE+CH E+ FAMILY Active Basic Plan Active Consumer Choice HSA Plan $48.18 $ $ $ $- $ $ $242.50

12 How Your Plan Works Fort Worth Fire 2019 Benefits 12 Health & Welfare Trust Medical Administrator Medical Cost Containment Prescription Benefit Manager

13 Maestro Health- Medical Administrator Fort Worth Fire 2019 Benefits 13 Maestro Health is the hub of your plan. They administer the medical benefits and can help with benefit questions and provide claims advocacy. Providers and facilities will work with Maestro and AMPS for payment of claims costs. Further details are included on the health benefits website under the Medical tab, at: Customer service and inquiries:

14 Kroger Pharmacy Benefits Manager Fort Worth Fire 2019 Benefits 14 Kroger Prescription Plans is the pharmacy benefit manager on your plan. Kroger develops the formulary and can answer questions related to RX coverage. Customer Service : rxplans@kroger.com Further details are included on the health benefits website under the Prescriptions tab, at:

15 AMPS- Cost Containment Service Fort Worth Fire 2019 Benefits 15 Your Health Plan has partnered with Advanced Medical Pricing Solutions (AMPS), to combat rising healthcare costs. AMPS handles the negotiations between your plan and providers / facilities and works with Maestro to pay a fair price to providers and facilities that you use for your healthcare. AMPS will assist plan participants with any balance billing type issues. Further details are included on the health benefits website under the AMPS tab, at:

16 LBG Advisors Additional Support Fort Worth Fire 2019 Benefits 16 LBG Advisors, LLC is the plan consultant. Our firm helps participants with claims issues that may occur on the plan. If you have called Maestro (medical) or Kroger (prescription) and do not feel they are handling your situation the way you want, please contact LBG Advisors at: Further details are included on the health benefits website under the MORE tab, at:

17 Local 440 Benefits Fort Worth Fire 2019 Benefits 17 Please see web site for more information. Call for Customer Service and benefit questions.

18 Required Notices Fort Worth Fire 2019 Benefits 18 The U.S. government requires companies offering certain employee benefit plans to inform covered participants and their dependents about laws/provisions that affect the governance and/or coverage within those plans. The company has full details available for you concerning the following laws/provisions: Notice of HIPAA Special Enrollment Rights Wellness Program Disclosure Notice of Alternative Standard Medicare Part D Notice Children s Health Insurance Program (CHIP) Notice Grandfather Status Notice of Patient Protection Provisions COBRA Notice Medical Child Support Order Notice Women s Health and Cancer Rights Act Summary of Benefits and Coverage Mental Health Parity and Addiction Equity Act (MHPAEA) Notice Summaries of each can be found in the Your Required Notices brochure. For complete information and more detailed explanations about any of these notices, contact Liza Spooner, Human Resources. Also, from time to time, you may receive detailed explanations directly from the company via letter or .