Transition of Medical Benefits to the Trust

Transcription

1 Transition of Medical Benefits to the Trust A Reference and Resource Guide for UAW- Ford Union Benefit Representatives This guide provides information on Ford benefits under the UAW Retiree Medical Benefits Trust. The Trust was created for eligible UAW Retirees of Ford as established under the 2007 Collective Bargaining Agreements, and became effective in The information included further describes the various life cycle stages of medical and prescription drug benefits in retirement. This guide is a supplement to the Summary Plan Description (SPD), Schedule of Benefits and Benefit Highlights; therefore in cases where discrepancies exist the Plan Document will rule. This guide is intended for Ford Union Benefit Representatives only. UAW Retiree Medical Benefits Trust 3/1/2017 DO NOT DISTRIBUTE WITHOUT PERMISSION

2 Table of Contents UAW Retiree Medical Benefits Trust (VEBA). 3 History of the Trust.. 4 Medical Benefits at the Trust Pre-retirement and Retirement Initiation.. 7 Rolling Enrollment / Plan Changes Health Plans Available Split Medicare Families. 11 Life Events Address Changes.. 12 Dependent Coverage. 12 Dual Coverage. 14 Medicare...15 Death Reporting Ford Retiree to Surviving Spouse/Domestic Partner Transition. 21 Pharmacy Benefits First Fills and Mail Order. 22 First Fills and Mail Order for Express Scripts Medicare PDP Retail Refill Allowance/Retail Incentive Program (Mandatory Mail) Paying for Mail Order Prescriptions Low Cost Generics Medicare Part D Extra Help Prescription Drug Assistance Program for Members with Low Income Medicare Part D High-Income Individuals Frequently Requested Prescriptions Not Covered Specialty Medications Coverage for Medicare Part B Drugs. 27 Allergy Serums, Non-Self-Administered Injections, & Insulin/Syringes.. 27 Prescription ID Cards for Each Medical Plan.. 28 Copay Reviews and Prior Authorizations 28 Appeals PHI Authorization Instructions & Form Helpful Resources & Tips Things to Keep in Mind Resources & Contact Information Retiree Health Care Connect (RHCC) Website Trust Website Benefits Quick Reference Benefits Quick Reference.. 39 Page 2

3 This guide is a supplement to the Summary Plan Description (SPD), Schedule of Benefits and Benefit Highlights; therefore in cases where discrepancies exist the Plan Document will rule. UAW Retiree Medical Benefits Trust (VEBA) The UAW Retiree Medical Benefits Trust is the official name of the Voluntary Employee Beneficiary Association (VEBA) responsible for providing UAW retirees of GM, Ford and Chrysler with medical and prescription drug benefits. It is also referred to as the UAW VEBA, UAW Trust or in most documents and for the purpose of this guide the Trust. The goal of the Trust is to provide the retiree population with comprehensive health care coverage which improves the health and well-being of retirees. The Trust follows a strict Code of Ethics to act in the best interest of the members and the Trust. Additional Information on VEBAs VEBAs are trusts that hold funds to meet the cost of health and welfare benefits. These trusts can be funded by employer contributions, employee contributions or both. VEBAs established under collective bargaining agreements benefit from tax-deductible contributions and tax-free accumulation of earnings. Section 501 (c) (9) of the Internal Revenue code establishes a VEBA s tax-exempt status. A VEBA must be an employees association a group of employees who associate together to receive benefits and have an employment-related common bond. Membership in the association must be voluntary. Union employees are a common example of an employees association for this purpose. The UAW Trust is a bit different, as it is comprised of three EBAs (employees beneficiary associations) one for each automotive company. General VEBA Considerations The populations of VEBAs are geographically dispersed. Membership is made up of retirees and surviving spouses and their dependents only. There are significant challenges facing VEBAs today, as it is difficult to predict investment returns and estimate future liabilities. In order to estimate future liabilities, it is necessary to make projections regarding factors that are necessarily uncertain and difficult to predict, including: Life expectancies Enrollment and retirement patterns Effects of medical care inflation Changes in use of health care services (behavior and utilization) Changes in Medicare benefits or payment levels Effects as a result of Health Care Reform legislation Page 3

4 History of the Trust The UAW Trust was created as a result of the 2007 UAW Settlement Agreements with General Motors, Ford, and Chrysler. The UAW and respective automotive companies negotiated terms to establish a VEBA to take over responsibility for administration and delivery of UAW retiree medical benefits beginning January 1, This provided the opportunity for automotive companies to move liabilities (sometimes referred to as legacy costs) off their financial statements; allowing them to be more competitive in the global market. These 2007 Settlement Agreements were also reviewed and approved by the federal courts. At the time of these changes in 2007, each of the companies took the position that it had the right to completely terminate retiree medical coverage at any time. The companies argued that the labor agreements did not create lifetime medical care. The UAW had fought this lifetime benefit issue in court many times with other companies. While the UAW had been successful in many situations defending the rights of retiree groups to receive continued retiree medical care under UAW labor agreements, the outcome of each case depends on many factors. Sadly, some courts in other cases had supported the company position on this issue. If the companies had prevailed in their argument, and convinced the judge that they had the contractual right to terminate benefits, the companies would have been free to completely eliminate the retiree medical coverage for UAW retirees. The UAW did not want the retirees to be exposed to this kind of risk. The 2007 Settlement Agreements therefore provided important protections for retirees. Those Settlement Agreements required the companies to make a series of financial contributions to the UAW Trust. These contribution obligations were fixed when the courts approved the 2007 Settlement Agreements, thus eliminating the risk that the companies could later argue that they had no obligation to provide retiree medical benefits. The 2007 Settlement Agreements provided another important protection for retirees. Prior to the 2007 Settlement Agreements, the companies were under no obligation to set aside funds to provide for future retiree medical benefit costs. Thus, retirees were completely dependent on the future financial health of the company; if the company went out of existence, there were no funds set aside to provide for on-going medical benefits. Under the 2007 Settlements, the company was required to make contributions to the Trust and, as the assets in the Trust grow, the retirees become independent from the future financial health of the companies. In summary, the 2007 Settlement Agreements changed the risk profile for retirees in several significant ways: The retirees are no longer exposed to the risk that the companies would be able to terminate the benefits completely by convincing a judge that the benefits were not lifetime. This protection proved to be of vital importance during the bankruptcy and restructurings of 2009, since it prevented any creditor from arguing that the company should seek to terminate retiree medical benefits on this basis. Page 4

5 As the Trust is funded, the retirees become independent of the risks associated with deterioration of the financial health of the company. The Trust invests its assets in a broad portfolio, and thereby protects the retirees from situations where the future financial health of a single company can lead to elimination of the benefits. The amount of funding for the Trust was determined in the 2007 Settlement Agreements based on a series of projections, as described above. If actual experience is worse than the projections, the Committee will need to make on-going adjustments to the benefit levels to keep the on-going benefit levels aligned with the assets of the Trust. During 2007 bargaining, the UAW concluded, and the federal courts agreed, that taking on the risk of these types of on-going adjustments, while at the same time eliminating the all or nothing risks described in the two bullet points above, was clearly in the best interests of the retirees because it would provide the retirees with the greatest certainty that their core medical benefits would continue on a long-term basis. The amount of the company contributions required under the 2007 Settlement Agreements was calculated based on a series of projections, as outlined above. Unfortunately, since the fall of 2007 when those contribution amounts were first established, several events outside the control of the UAW or the Trust have already created a strain on some of the funding assumptions that were part of the 2007 Settlement Agreements: Many of the funds called for in the 2007 Settlement Agreements were set aside in trust funds administered by the companies on January 1, Those funds which were to be invested on behalf of the retirees and then contributed to the UAW VEBA on January 1, 2010 were therefore exposed to the meltdown in the financial and investment markets in While the investment markets have recovered since 2008, that recovery has not yet put the Trust s investments on the same footing as was originally projected back in The bankruptcy of GM and Chrysler, and the restructuring of Ford, as described below, required a re-negotiation of some of the important funding parameters, in order to allow the companies to avoid complete liquidation. Had the companies liquidated during the crisis of , they would have been unable to meet the funding obligations set out in the 2007 Settlement Agreements. The UAW, on behalf of the retirees, therefore supported a series of changes in the funding and benefit designs, all of which were approved by the bankruptcy courts (in the case of GM and Chrysler) or the federal court (in the case of Ford). The financial crisis also led to a whole series of dramatic changes in the operating profile of the companies, including many plant closings. These plant closings often caused employees to retire earlier than originally projected. These additional early retirements led to additional liabilities for the Trust, and were not reflected in the original funding projections in Page 5

6 Finally, the 2007 Settlements included several mechanisms to allow the Trust to benefit from future equity appreciation at the companies. Given the meltdown of , the equity value of GM and Chrysler was essentially wiped out. While Ford did not experience a bankruptcy event, the restructuring that Ford went through in early 2009 had a negative impact on the value of this component of the 2007 Settlement Agreement at Ford as well. In summary, the 2007 Settlement Agreements eliminated a series of all or nothing risks that previously threatened the very existence of on-going medical benefits for UAW retirees. Under the 2007 Settlement Agreements, however, the Committee is responsible to make sure that on an on-going basis the assets of the Trust are in line with the benefit levels Auto Bankruptcy Changes to Benefits and VEBA Funding The collapse of the banking industry at the end of 2008 put the U.S. economy in the worst recession since the Great Depression. New vehicle sales dropped to all-time lows, and Chrysler and General Motors could not secure funding desperately needed to keep them afloat. As a result, both Chrysler and General Motors filed for bankruptcy. The unprecedented proceedings allowed both companies to emerge from bankruptcy swiftly and better positioned for long-term survival. This however did not come without sacrifices from all parties including workers and retirees. As a condition of the bankruptcy and loans granted by the federal government, benefit changes were mandated. These modifications allowed pension benefits to remain intact but resulted in higher copayments for prescription drugs and office visits, along with the loss of dental and vision benefits for current and future retirees. The loss of dental and vision benefits did not affect UAW-Ford members. (However, effective 2015, comprehensive dental and vision benefits have been restored for GM and Chrysler retirees under the Trust coverage.) Furthermore, VEBA funding was largely comprised of company stock shares and warrants with undetermined value until such a time both companies can be publicly traded in the markets. An Independent Trust In line with the 2007 Agreements, the courts approved the UAW VEBA as an independent trust. The Trust is not operated by the UAW. Oversight of the Trust is provided by 11 Trustees on the Committee; of which six (6) are independent Trustees approved by the court and five (5) are UAW-affiliated representatives. Many Trustees also serve on the Audit, Investment, and Plan Administration and Vendor Performance Subcommittees. Separate Funding with Shared Administration The Committee has the responsibility for designing and delivering medical benefits to eligible UAW retirees, surviving spouses and dependents. To provide these benefits, the Committee can use only assets available in the VEBA Trust Fund. The Trust is required to maintain three separate accounts, one each for GM, Ford and Chrysler retirees. Health care benefits for Ford retirees can only be paid from the Ford account and cannot be paid out of the accounts set up for retirees from the other two companies. Page 6

7 The Committee hired a team of health care and investment professionals at the Trust. The Committee has worked closely with the Trust staff to transition billions of dollars of investment assets received from the auto companies, to develop systems, and processes to operate the Trust and its health care programs into the future. The UAW Retiree Medical Benefits Trust successfully launched January 1, In the first month of operation, ID cards covering approximately 872,000 members were distributed; over 300,000 member calls were handled by call centers and 1 million prescriptions were processed. On an on-going basis, the Committee reviews the level of Trust assets compared with benefit costs, and makes adjustments as needed. Normally, any adjustments to the benefits will be done on a calendar year basis, and retirees will be notified in early fall of the year before any changes take effect. The UAW and the Trust staff will notify Benefit Representatives as these retiree communications are being distributed, so that Benefit Representatives can help retirees understand the background for these changes in advance. Summary: Impact of Economic Events Since 2007 In view of the dramatic events in the auto industry and the investment markets since 2008, the Committee has in fact been called upon to make some adjustments to the benefits. Whether future adjustments will be required and if so to what degree will depend on events in the health care and investment markets that are largely outside the control of the Committee. Each December, the Trust will mail its members the Summary Annual Report (SAR) for UAW-Ford Trust members, which is required by law. This document will provide members with information about the Trust s financial status. Additionally, members can request a copy of the SAR by contacting Retiree Health Care Connect (RHCC) at or online at Medical Benefits at the Trust Pre-Retirement and Retirement Initiation When an employee makes the decision to retire, they should be advised that their coverage through the Trust as a retiree differs from their active employee coverage with Ford in the following ways: Monthly contributions may be required Eligibility rules for dependent children are different Some carriers and plan options are different Traditional Care Network (TCN) plans have deductibles, copays and out-of-pocket maximums HMO plans have deductibles Health Plans have benefit coverage differences compared to active plans Dental and vision benefits may have coverage differences compared to active plans Prescription drug copays are higher *Additional information can be found in the Summary Plan Description, Schedule of Benefits and Benefit Highlights. Page 7

8 Keep in mind the health plan options at the Trust may be different than those at Ford. If the health plan is available, all data, including dependent information, will automatically transfer to the current plan. If the health plan is not available, the retiree and any dependents will be transferred to Blue Cross Blue Shield Traditional Care Network (TCN). If other plans are available in the geographic area, the retiree can make a plan option change by contacting Retiree Health Care Connect (RHCC) within 30 days of retirement and the plan change will be retroactive to the date of retirement. If the retiree contacts RHCC after 30 days of retirement, he or she will be able to make the plan change based on rolling enrollment rules. Plan changes based on rolling enrollment rules will be effective the first day of the second month following the change request. All retirees will receive new ID cards from the health plan carriers. Retirees may be required to contribute monthly toward the cost of their health care. In 2017, the monthly contributions are $17 single and $34 family. For all members who enroll in a Medicare Advantage PPO plan for 2017 (if available in area), the Trust will waive monthly contributions. Contributions are set for automatic pension deduction unless otherwise indicated or if sufficient funds are not available. Retirees or surviving spouses unable to have their monthly contributions deducted from their monthly pension payments are encouraged to sign up with RHCC for direct debit to avoid disruption in health care coverage. Retirees should also be aware that deductibles and copayments for the health plans may be different than those of active employees. A Summary Plan Description, Schedule of Benefits and Benefit Highlights are sent to new retirees upon receipt of retirement information at RHCC. Effective January 1, 2013, the Trust implemented a group-sponsored Medicare Part D prescription drug plan for Medicare-eligible members. The prescription drug plan, offered through Express Scripts Medicare (PDP) on behalf of the Trust, allows the Trust to better manage retiree prescription drug benefits and costs. The overall benefit remains similar to the non-medicare prescription drug coverage. For example, the three-tier copay structure, 90-day mail order program and a requirement of prior authorization for certain medications remain the same. Preventive care is the most important step members can take to manage their health, because many of the top risk factors leading to illness and premature death are preventable. In 2012, the Trust added primary care office visit coverage for non-medicare members enrolled in the TCN plan. In 2015, the Trust added two additional primary care office visits for non-medicare members enrolled in the Traditional Care Network plan at a $25 copay per visit. Members now have a total of six (6) annual primary care visits. Covered practices include Family Practice, General Medicine, Internal Medicine, Geriatrician, OB/GYN, Pediatrician, Nurse Practitioner and Physician Assistant. Effective January 1, 2015, in-network retail clinics are covered as an approved site for urgent care services. Retail clinics are usually open seven days a week and located mostly in grocery and pharmacy store chains. Please note that retail health clinic networks are limited and evolving in various areas. Retail Clinics are covered under the urgent care copay at $50 ($25 copay for Page 8

9 Medicare Advantage Plan members) per visit. Coverage is available for in-network clinics only. Members should contact their health plans for in-network locations in their area. Effective with the retirement date, the Trust provides dental and vision coverage to members and their eligible dependents at no additional cost to members. A Dental Benefits Manager, Delta Dental of Michigan, administers dental coverage to most retirees. (Midwestern Dental DHMO is available in Michigan.) If a member is enrolled in a Health Maintenance Organization (HMO) that does not provide Vision Care Coverage, SVS Vision administers vision coverage. Contact information for Delta Dental of Michigan and SVS Vision is listed in the Resources and Contact Information section of this booklet. Since health care coverage is being transferred to the Trust, a separate entity from Ford, employees should be encouraged to start the retirement process at least 90 days prior to the effective date to allow for the transfer of data as indicated below. Page 9

10 Ford Retiree Transition to Trust Coverage Retiree alerts Ford of retirement by contacting UAW Benefit Representative Ford/ACS sends retirement info to RHCC as well as current coverage & dependent information. Files are sent five (5) times a week (M-F) New retirement information is loaded into RHCC system Coverage enrollment event completed Weekly update files are sent to carriers following the enrollment event Carrier mails ID cards to retiree within 7-10 days of the date of notification RHCC sends welcome/notification packet to retiree. This includes the SPD, Schedule of Benefits, Benefit Highlights, plan options, etc. Around the 9 th of the month prior to the start of Trust coverage RHCC attempts to collect the monthly contribution via pension deduction. This deduction may include retroactive amounts ACS returns a file to RHCC indicating if a deduction was taken to complete the reconciliation process Example for a retirement event John calls his UAW Benefit Rep to retire on April 19 for a June 1 retirement date. ACS sends RHCC the participant s current health care plan information and dependent information on April 20. RHCC builds the participant data in their system on April 21. Data files with the retiree s retirement/health care information are sent to the carrier on April 28. The retiree will also receive their retirement welcome kit during the week of April 26. Carriers will receive the enrollment information and process ID cards within 7-10 business days of loading the data into their system. The retiree should have the new ID card by the second week of May, prior to the June 1 retirement date. If the ID card is not received, the member will need to contact the carrier. The member can obtain the carrier phone number through Retiree Health Care Connect or online at RHCC will attempt a pension deduction for up to three (3) consecutive months. If there are sufficient funds available, then payment will automatically be deducted from the monthly pension going forward In the event that a deduction cannot be taken, RHCC sends a direct bill (this may include retroactive amounts owed) with an effective date to pay the 1 st of following month and instructions for enrolling in direct debit Page 10

11 Rolling Enrollment / Plan Changes If there are other plans available in the retiree s geographic area, the new retiree may elect another health care plan option. Additional considerations: All new retirees transferred to the Trust have the opportunity to make a health care plan change within 30 days if other plans are available. Changes made within 30 days will become effective on the date of retirement. If an election is not made within 30 days, the retiree will be required to use a rolling enrollment process to make a health care plan change If a new health care plan becomes available, all members in the service area will be given the opportunity to enroll in the new plan overriding the rolling enrollment rules Health Plans Available Plans in which retirees are eligible to participate are HMO, Medicare Advantage PPO (available in certain locations for Medicare-eligible members) or Traditional Care Network plan options. Not all plans are available state-wide, however, the Blue Cross Blue Shield MI Traditional Care Network plan is available nationwide. Retirees may contact RHCC via the web or phone for specific information about available plan options or to make a change. Split Medicare Family Effective January 1, 2016, households that consist of members enrolled in Medicare coverage and others who are not covered by Medicare (known as Split Medicare Family ) are allowed to split medical plan elections between available Non-Medicare and Medicare plan options. This medical plan option flexibility allows Medicare members the opportunity to enroll in Medicare medical plan options, such as a Medicare Advantage plan, while Non-Medicare members may be enrolled in TCN or an HMO (where available). Cost Sharing details can be found in the Benefit Highlights and are also available online at Page 11

12 Life Events Address Changes It is important for members to keep their addresses up-to-date to make sure they continue to receive Trust updates and other mailings regarding their benefits. Retirees and surviving spouses must update their address at RHCC on the website or via phone for health care purposes. Address changes must also be provided to the pension administrator. Must contact RHCC for address changes Retirees can also choose to update their records with an alternative (or temporary) address. A permanent address is the retiree s primary home. An alternative (or temporary) address can be used by retirees who spend several months away from their primary home. An alternative (or temporary) address change does not change the current health care plan. When a retiree makes a permanent address change, they may need to change health care plans, since plan offerings are based on ZIP codes. When the retiree changes a permanent address and the current health care plan is available the retiree will only receive a confirmation of address change either on the website or in the mail (depending on how they made the change). If the retiree changes a permanent address and their current health care plan is no longer available, the retiree will be transferred to the Traditional Care Network and will have 30 days to change to any other plan available (retroactive to the date of the address change). Retirees who have other plans available will receive an address change confirmation and new plan enrollment information either in the mail or on the web, depending on how they make the change. Plan changes made within 30 days of an address change are considered Qualified Status Changes and are not subject to rolling enrollment guidelines. Changes made outside the 30-day period will be processed as part of the rolling enrollment process. All address changes are effective the 1 st of the month following notification of the address change. Dependent Coverage Dependent Eligibility Dependents (spouse, same-sex domestic partners and children) of retirees on coverage at Ford will automatically transfer to the Trust. A common-law spouse is eligible for coverage if the relationship is recognized by the laws of the state in which the retiree is enrolled. In order for children to be eligible for coverage under the plan they must meet all five eligibility tests. The eligibility criteria are different than the Ford rules. Retirees may add children as dependents, but Surviving Spouses/Same-Sex Domestic Partners may not. The five eligibility tests include: Page 12

13 Relationship natural child, stepchild, legally adopted. Legal guardian children may remain on coverage until age 18 Age may be eligible until the end of the month in which they reach age 26. Children determined to be Permanently and Totally Disabled (PTD) may continue health care coverage beyond the age of 26. Retirees can request a Disabled Dependent Certification Package from RHCC by phone or online. A child is considered to be PTD if they were PTD prior to the end of the month in which they turn age 26, has a medically determinable physical or mental condition that prevents the dependent from engaging in substantial gainful activity and which can be expected to result in death or be of long-continued or indefinite duration and the dependent must not earn more than $10,000. The PTD dependent must meet all other eligibility requirements. Marital Status unmarried Residency must live with the primary enrollee Dependency can be claimed as an exemption on retiree s Federal income tax Adding Dependents to Coverage Retirees (not surviving spouses or same-sex domestic partners) can add spouses and dependents to coverage by contacting RHCC at Retirees may not add a new Same-Sex Domestic Partner or children of the Same-Sex Domestic Partner after their retirement effective date. However, members can add a Same-Sex Spouse after their retirement effective date, provided they are legally married. When contacting RHCC, retirees must provide the date of birth and Social Security Number for the dependent being added. If the retiree requests the dependent be added within 30 days of the following events, coverage will become effective on the date of the event. Marriage Birth or adoption o Court order/qualified Medical Child Support Order (QMCSO) If the retiree requests the dependent be added more than 30 days after the date of the event, the effective date will be the first of the month following the request. The retiree will be required to provide birth certificates and marriage certificates within 30 days of the request to add a dependent. The retiree will receive a confirmation of enrollment via the web or mail, depending on how the retiree prefers. The information regarding the new dependent will be sent to the carrier following the enrollment. After the carriers receive the information from RHCC it will take about 3-5 business days to load the data into their system. Retirees should expect to receive ID cards for the newly added dependent, if necessary, within 7-10 business days after receipt of the file. Page 13

14 Important reminders when adding dependents In most cases, paperwork is not required at the time dependents are added. After a dependent is added, however, the retiree will be required to provide documentation as proof of eligibility. Paperwork must be received when a participant is requesting to add a Legal Guardianship or Court Order/QMCSO dependent before the dependent can be added. Legal Guardian dependents will be effective the 1 st of the month after the receipt and approval of the requested documentation. Participants requesting to add a Legal Guardianship Dependent will be asked to provide a copy of the legal guardianship papers (stating full and permanent custody), proof of residency, and the last Federal 1040 filed The first five digits of the Social Security Numbers and income figures may be concealed for privacy and security Participants who are adding a Court Order/QMCSO dependent will be asked to provide a full copy of the court document Documentation should be sent to: UAW Retiree Medical Benefits Trust Attn: QMCSO/ Dependent Eligibility PO Box Detroit, MI The Trust will conduct periodic audits to ensure that all dependents remain eligible for coverage. During these audits, retirees may be required to provide proof of eligibility for all dependents. Removing Dependents from Coverage It is the responsibility of the retiree to contact RHCC when dependents become ineligible for coverage. Dependents who no longer meet the five eligibility tests should be removed from coverage. Spouses should be removed in the event of a divorce. Please note: it will be the contract holder/member s responsibility to pay for any fees (claims, premiums, etc.) associated with ineligible dependents. Dual Coverage Since January 2010, the Trust is responsible for health care coverage for retirees from all three autos. As a result there are a number of retirees who have dual coverage under the Trust. For example, the retiree may be a retiree from Chrysler and a spouse of a Ford retiree; or a Ford retiree and a GM surviving spouse. Retirees are eligible to maintain dual coverage but it may not be in their best interest to enroll and pay for coverage for more than one plan. Coordination of Benefits rules do not allow payment to be made from the secondary plan for services in excess of what would have been paid if the plan was primary. The Trust will continue to reach out to these retirees/surviving spouses to explain their options and attempt to save money for the retiree/surviving spouse as well as the Trust. Page 14

15 Medicare Overview The UAW Retiree Medical Benefits Trust strongly encourages retirees/surviving spouses and dependents to enroll in Medicare Part B when first eligible for three main reasons: 1. The Trust will begin to process claims as if a member is enrolled in Medicare Part B when first eligible regardless if the member chooses to enroll; so enrollment into Medicare Part B will help members avoid higher out-of-pocket expenses 2. Timely enrollment helps to avoid Medicare penalties for late enrollment into Medicare Part B. The cost of the Medicare Part B premium increases 10% for each full 12-month period an individual was eligible and did not enroll 3. Surviving spouses or surviving same-sex domestic partners that are age 65 or older must be enrolled in Medicare Part B to continue to be eligible for Trust health care benefits Example: If a service is covered by Medicare at 80%, the Trust health care plan would cover the rest of the service at 20% (after Medicare Part B deductible is met). In this case, health care services are first billed to Medicare, and then the Trust health care plan. Monthly Medicare Communications & Call Center Assistance Eligible members that are enrolled in medical coverage through the Trust and are approaching age 65 will receive up to three letters regarding Medicare enrollment. The first letter is mailed to all members 90 days before their 65 th birthday. This letter includes information regarding why it s important to enroll in Medicare, how to enroll in Medicare, Medicare prescription drug coverage and how Medicare enrollment may impact the members health plan election. The second and third letters are only sent to members that just turned 65 years old and are not showing as enrolled in Medicare Part B. These letters are reminder letters to ensure the member understands the Trust Medicare policy and the potential higher out-of-pocket health care expenses and possible Medicare premium penalties if they do not enroll when first eligible. 1. First Letter mailed by RHCC to all members 90 days prior to their 65 th birthday 2. Second letter mailed only to members that are not yet showing with Medicare enrollment in month of their 65 th birthday 3. Third letter mailed only to members that are not yet showing with Medicare enrollment the month following their 65 th birthday Retiree Health Care Connect will assist members with any general Medicare questions. Retiree Health Care Connect can be reached at Page 15

16 Medicare Communications & Call Center Assistance for those under 65 and enrolled in Medicare Part A only Members that are under age 65 and enrolled in Medicare Part A only are eligible to enroll in Medicare Part B. In order to avoid higher out-of-pocket expenses, RHCC will reach out to these members to encourage them to enroll in Medicare Part B and to further explain how the Trust coordinates health care claims with Medicare. 1. First Letter RHCC will identify all new members that are enrolled in Medicare Part A only at the beginning of each month and have not received any Medicare communications from the Trust. RHCC will mail a letter advising of the Trust Medicare policy and the importance of enrolling in Medicare Part B along with the necessary steps of how to enroll. 2. Second Letter Two months after the above letter is mailed, RHCC will check if the members have enrolled in Medicare Part B and if not, they will send a reminder letter. Retiree Health Care Connect will assist members with any general Medicare questions. Retiree Health Care Connect can be reached at Medicare General Enrollment Period Communications & Call Center Assistance Every year Medicare offers a general enrollment period for all Medicare beneficiaries that did not enroll in Medicare Part B when they first became eligible. The general enrollment period begins January 1 st and runs through March 31 st of each year. If a member enrolls during this time their Medicare Part B coverage will become effective July 1 st. The Trust has established an annual Medicare Enrollment Campaign to notify members of this enrollment period, the importance of enrolling in Medicare Part B and the necessary steps to enroll. 1. First Letter mailed by RHCC in the month of December to all members that are presently showing as enrolled in Medicare Part A only 2. Second letter mailed in the month of January to all members that are showing as enrolled in Medicare Part A only 3. Third letter mailed in the month of February to all members that are showing as enrolled in Medicare Part A only Members should be directed to call Social Security directly to enroll in Medicare at All other general Medicare questions should be referred to Retiree Health Care Connect at Page 16

17 Social Security Disability Insurance (SSDI) & Medicare for under age 65 The Trust has partnered with Public Consulting Group (PCG) to assist retirees, surviving spouses and their eligible dependents to enroll in Social Security Disability and Medicare at no cost to the member. PCG will contact members by sending introductory letters, providing background information on PCG and the potential benefits available to the member. The initial mailing will include a short questionnaire regarding the individual s disability and work history, to be completed and mailed back within the provided prepaid envelope. PCG is available via phone, with a dedicated staff, to assist members with any questions and to ensure members are completely comfortable with the application process. If Trust members are interested in this service they may call and speak with a representative. Below is the contact information for Public Consulting Group: 200 Fair Street Ste. 2 Clarkston, WA Phone: Fax: Online: PCG also offers services to assist Medicare members who may qualify for Extra Help, a Medicareapproved program that can help save on Medicare Part D prescription drug copayment costs. More information on this program can be found in the pharmacy benefits section. How Medicare Eligibility Impacts Health Care Plan Elections If members are eligible for Medicare and do not enroll, the Trust health care plans will process claims as if the member is enrolled in both Medicare Parts A and B. Members who are eligible and enrolled in Medicare Parts A and B may have several types of coverage options, depending on their geographic location an HMO Medicare Advantage plan, a Medicare Advantage PPO plan, or the Traditional Care Network plan (TCN). It is important for members to check with their health care providers to ensure they are a participating provider of the health care plan. As a reminder, Medicare Part D is a prescription drug coverage that is available to everyone with Medicare to help cover the cost of prescription drugs. Coverage under the Medicare Part D program can be direct to individuals who qualify for Medicare Part A and/or B or can be a group benefit sponsored by a former employer or retiree group. In 2013, the Trust implemented a group-sponsored Medicare Part D plan with wraparound coverage. This plan was created specifically for the Trust and is only available to its eligible retirees and dependents. Unlike an individual plan, members do not need to enroll in the Trust-sponsored plan; they are automatically enrolled. Please note it is important to remind members not to enroll in an individual Part D prescription drug plan as it will conflict with their Trust-sponsored coverage. Members may be eligible to elect a HMO Medicare Advantage plan or Medicare Advantage (MA) PPO plan option. When electing either of the Medicare Advantage plans, the member must assign (or transfer) Medicare Part A and B benefits from the federal Medicare program to the Trust health care plan. The Trust health care plan will coordinate payment of Part A and B claims on behalf of the government. If the member does not assign Medicare Parts A and B to the health care plan, the member will be moved to the Traditional Care Network (TCN) plan. In a Medicare Advantage plan, health care services are billed to the Page 17

18 plan directly (not Medicare). It is important for members to check with their health care providers to ensure that they accept the Medicare Advantage plan. Members may not continue enrollment in a Trust-sponsored Medicare Advantage plan if they choose to enroll in an individual Medicare Part D prescription drug plan. Members who enroll in a Trust-sponsored MA plan will automatically be enrolled in the Express Scripts Medicare (PDP). This is the only prescription drug option available for Trust-sponsored MA plans. With the Traditional Care Network plan option (TCN), the Trust health care plan pays as if a member is enrolled in both Medicare Part A and Medicare Part B and will pay charges as the secondary payer. All Medicare-eligible members enrolled in the TCN plan will be enrolled in the group-sponsored Medicare Part D prescription drug plan for Medicare members offered through Express Scripts Medicare (PDP). Members in the TCN plan, who choose to enroll in an individual Medicare Part D plan, can remain in the TCN plan. However, prescription drug coverage provided by the Trust will be suspended for any members that are enrolled in an individual Medicare Part D plan. (Their medical coverage will continue in the TCN plan.) Example: If a member requires a medical service that is $2,500 and Medicare s allowed amount for the service is $2,000, Medicare would pay 80% of the allowed amount and the Trust would pay 20% coinsurance. Once the member has satisfied the Part B Deductible, the Trust would pay $400 because Medicare would have paid $1,600, and the claim would be considered paid in full. If a member is eligible for Medicare Part B and chooses not to enroll the Trust will still pay $400, and Medicare will pay nothing. Payer Member Responsibility When enrolled in Medicare Part B Total charge for medical service $2,500 $2,500 Medicare allowed amount $2,000 $2,000 Medicare Part B payment 80% of the approved amount $1,600 $0 Trust payment (After Medicare Part B deductible is met) $400 $400 Member Responsibility $0 $2,100 When not enrolled in Medicare Part B In this case, health care services are first billed to Medicare, and then the Trust health care plan. Medicare Parts A and B remain assigned to the federal Medicare program. It is important for members to check with their health care providers to ensure that they accept both Medicare and the Trust health care plan. Page 18

19 Frequently Asked Questions: Medicare Q. Why do I need to enroll in Part B when I have medical coverage through the Trust? A. If you do not enroll in Medicare Part B, you will be responsible for expenses that would normally be covered by Medicare Part B. Q. I am a surviving spouse. If I do not enroll in Part B will I lose my medical coverage through the Trust? A. Yes, if you are not enrolled in Part B your Trust medical coverage will be cancelled. If you later decide to enroll in Part B you may re-enroll in Trust coverage; however, you may have to pay a penalty that will increase your monthly premium for Medicare Part B if you did not enroll when first eligible. Q. I was told by Social Security that I m not eligible to enroll in Medicare Part B. Why am I receiving letters telling me to enroll? A. Social Security may not have looked at all of the enrollment periods or may not have the correct personal information for you. You should contact Retiree Health Care Connect for further assistance at Q. I have Medicare but the Retiree Health Care Connect (RHCC) is saying they do not have my Medicare information. Why do they not have this information? A. RHCC receives Medicare information every 4-6 weeks through a Voluntary Data Sharing Agreement between the Trust and the Centers of Medicare & Medicaid (CMS). Q. My wife just turned 65 and I m only 62. Why does she need to enroll in Medicare now? A. The Trust will begin to process her claims as if she is enrolled in Medicare Part B and she will be responsible for all outpatient and physician claims that Medicare Part B would have paid and the Trust will pay as the secondary coverage only. Also, if she delays her enrollment in Medicare Part B she will have to pay a higher monthly premium. The cost of the Medicare Part B premium increases 10% for each full 12-month period an individual was eligible and did not enroll. Page 19

20 Medicare Specific Contact List Subject Detail Contact Will enrollment in Medicare change my health plan carrier How does Medicare work with my Trust coverage How are my Trust benefits affected by enrolling or not enrolling in Medicare I m now enrolled in Medicare, does this change my families coverage through the Trust What happens if I do not enroll in Medicare Part B General Medicare Questions Medicare Eligibility/ Enrollment Medicare Claims, Coverage & Cost Health Plan Claims Social Security Disability Insurance (SSDI) Extra Help for Medicare Part D Prescription Drugs Am I eligible for Medicare Why haven t I received a Medicare Card Why did I receive a Medicare Card, I m not 65 I lost my Medicare card and need a new one The name on my Medicare Card is wrong How or when should I enroll in Medicare Questions regarding specific procedures and are they covered by Medicare Questions regarding specific providers and are they participating with Medicare How much will I pay for Medicare coverage Medicare denied my claim Questions regarding specific procedures and are they covered by my Trust coverage Questions regarding specific providers and are they participating with my Health Plan My health plan did not pay my claim and I received a bill from my provider Questions regarding Social Security Disability Enrollment Questions regarding qualification for Extra Help for savings on Medicare Part D prescription drug copayments Retiree Health Care Connect (RHCC) Phone: Social Security Administration (SSA) Phone: Medicare Phone: Health Plan - Contact information found on the back of the medical ID card Public Consulting Group (PCG) Phone: Public Consulting Group (PCG) Phone: extrahelp@pcgus.com Page 20

21 Death Reporting In the event of the death of a retiree, dependents will remain on coverage through the end of the month of the death. If the retiree has a covered spouse or domestic partner, a surviving spouse/surviving domestic partner contract under the Trust will be effective the first of the month following the retiree s date of death. Eligible dependents will be transferred to the new surviving spouse/surviving domestic partner contract. The surviving spouse/surviving domestic partner will still be required to pay monthly contributions; the amount may be lower if the surviving spouse/surviving domestic partner does not have any eligible dependents. The death of a retiree, surviving spouse or dependent should be reported to RHCC. If the surviving spouses/surviving domestic partner is entitled to a Ford pension benefit and the monthly contributions were taken from the retiree s pension payment prior to the retiree s death, the monthly contributions will be taken directly from the survivor s pension payment. If the pension amount is insufficient for the monthly contribution or the surviving spouse/surviving domestic partner is not entitled to a pension they will be offered the opportunity to pay their monthly contributions through direct debit or monthly invoices. If there is no spouse or domestic partner on coverage but there are other dependents, the dependents will be offered the opportunity to continue health care coverage through COBRA effective the first of the month following the retiree s death. Ford Retiree to Surviving Spouse/Domestic Partner Transition The following outlines the various activities associated with retiree to surviving spouse contract transition: Death of the retiree reported to RHCC Surviving spouse/surviving domestic partner record built at RHCC A confirmation statement will be mailed by RHCC to the surviving spouse/surviving domestic partner RHCC will attempt a pension deduction for the monthly contribution. If a pension deduction cannot be taken after three consecutive months, the surviving spouse/surviving domestic partner will receive an invoice (totaling 4 months) and instructions for enrolling in direct debit The data file will be sent to the health plan carrier following notification of the death Once the health plan carrier receives the file it will take 3-5 business days to process the data in their system ID cards will be mailed within 7-10 business days of receipt of file at the carrier * In the event of the death of a spouse or dependent, their coverage will terminate effective the date of death. Page 21

22 Pharmacy Benefits Express Scripts is the Pharmacy Benefit Manager for members of the Trust enrolled in the TCN plan, most HMO plans and all Medicare Advantage PPO plans. First Fills and Mail Order Members can order new prescriptions by mail or have a physician office place the order via fax or over the Internet on behalf of the member. It is recommended that the member ask the doctor for two (2) prescriptions on any medications that will be taken beyond 30 days. This allows: A 30-day supply to be obtained from in-network retail pharmacies and; A 90-day supply, plus refills up to one year (if appropriate) to be placed via mail order Members should order their refills when they have a two-week supply remaining on their current prescription. Refills can be ordered via the Internet at over the phone through Express Scripts Member Services at (Medicare members, press 1 at the prompt) or by mail. Generally medication is delivered within 8 days using standard shipping at no additional cost. First Fills and Mail Order for Express Scripts Medicare PDP Effective January 1, 2014, there were important changes that affected the mail-order home delivery pharmacy service for members enrolled in the Express Scripts Medicare PDP. In order to eliminate waste and unnecessary additional costs to you, the Centers for Medicare & Medicaid Services (CMS) now requires Express Scripts to get member approval before delivering any new prescription drug through home delivery, if the prescription was requested directly from a doctor. This new rule only applies to Express Scripts Medicare members who have not used the Express Scripts Pharmacy within the last 12 months. If the member has not used the Express Scripts Pharmacy in the last year and the prescription is ordered directly by a doctor, the member will need to give permission to the Express Scripts Pharmacy to fill that prescription. After the member provides consent, the prescription is delivered automatically, until the prescription expires. There are two ways to provide consent and request the medication: Contact Express Scripts Medicare Customer Service at , at the prompt, press 1. TTY users should call Log on to and select the prescription(s) that the member wants to receive through home delivery. If this is the member s first visit to the website, he or she will need to register. Page 22

23 If a prescription has not been submitted to Express Scripts directly by the member, it will be held in the Express Scripts system until the member provides consent for the first fill. For any new prescriptions requiring member consent, Express Scripts will contact the member through automated phone messages and/or by mail to obtain approval. Once the consent is received, the prescription will be processed and mailed to the member. Members do not have to provide consent for each refill. Once the member has authorized Express Scripts to process a renewed prescription, the refills for that prescription will continue to ship automatically, as usual, until the prescription expires. Retail Refill Allowance/Retail Incentive Program (Mandatory Mail) Non-Medicare members who are on Maintenance drugs, those taken on an on-going basis (3 months or more - such as medications to treat blood pressure, diabetes or high cholesterol ), will be allowed up to 3 fills at a retail pharmacy. On the 4 th fill, the prescription must be filled through Express Scripts Mail Order to avoid paying the full cost of the drug at retail. Members receive a reminder letter from Express Scripts after the 3 rd fill at retail. Paying for Mail-Order Prescriptions Members may pay mail order charges in the following ways: Check Money order e-check Credit card *Extended payment options are available- call Member Services for additional information. Once a member accrues charges, payment will be required by Express Scripts. Members are encouraged to join Express Scripts automatic payment program to allow for credit card payments and uninterrupted service; members can enroll online at or call Low Cost Generics Members may choose to go to any pharmacy offering lower cost generics than what may be available through Express Scripts. In these cases, while there is no payment needed for members to process their card, doing so will check for potential drug interactions with other medications they are currently taking. Page 23

24 Information Members Receive on Low Cost Generics through Express Scripts $10 or less for a 90-day supply of more than 400 generics* Through your mail-order prescription drug benefit, you have access to more than 400 generic drugs, at the low cost of $10 or less for up to a 90-day supply. Plus you ll get: Access to pharmacists who are specially trained in medications used to treat a specific condition, such as high blood pressure, high cholesterol, depression, and diabetes Safety checks that help protect you from potential drug interactions Convenient delivery right to you, with free standard shipping Today, many brand-name drugs have generic versions, so it s becoming more common for patients to ask their doctors to prescribe generic drugs to treat their conditions. FDA-approved generic equivalents have the same active ingredients and must meet the same FDA standards for safety, quality, and effectiveness as their brand-name counterparts. For more information or to find out whether a 90-day supply of your generic drug is available for $10 or less, visit or call RxSAVE-NOW ( ). If you don t find your medication, check back from time to time, as this list may change. To find the lowest-cost alternatives for all your prescription drugs, visit Scripts.com/choices. * The $10 price applies to a 90-day supply of each generic drug in the commonly prescribed dosages shown on the program drug list. If your prescription is written for a different days supply or quantity, your cost may vary. The medications and pricing on the program drug list are subject to change without notice, so visit for the latest information. If your mail-order co-payment or coinsurance for generics is less than $10, you ll pay the lower amount. The coverage and pricing of certain medications are also subject to the specific terms of your plan. In certain states, sales tax may be added to the cost of your prescriptions. Page 24

25 Medicare Part D Extra Help Prescription Drug Assistance Program for Members with Low Income If a member qualifies for Extra Help paying for prescription drugs, the member s cost-sharing amounts may be lower than the standard plan benefit. Members who qualify for Extra Help will receive a notice called Important Information for Those Who Receive Extra Help Paying for Their Prescription Drugs ( Extra Help Rider ). This notice will provide information on what those member s costs are. Members can also contact Express Scripts Customer Service for more information. Medicare or Social Security will periodically review a member s eligibility to make sure that he or she still qualifies for Extra Help with Medicare prescription drug plan costs. A member s eligibility might change if there is a change in income or resources, marital status or if he or she loses Medicaid. Information Needed to Complete Extra Help Application Social Security Card or number; Bank account statements, including checking, savings, and certificates of deposit; Individual Retirement Accounts (IRA), stocks, bonds, savings bonds (including book entry securities*), mutual funds, other investment statements; Tax returns; Payroll slips; and Most recent Social Security benefits award letters or statements for Railroad Retirement benefits, Veterans benefits, pensions and annuities. Request and Complete an Extra Help Application Apply online at or Apply over the phone or ask for Form SSA-1020 by calling Social Security at (hearing impaired TTY ) Apply in person at the local Social Security office Apply by mail Call and request application be mailed to home Complete application and mail to: SSA PO Box 1020 Wilkes Barre, PA The Trust has also partnered with Public Consulting Group, Inc. (PCG) to assist Medicare members who may qualify for Extra Help with their Part D prescription drug copayment costs. PCG offers a comprehensive, personalized service, working directly with the member on the Extra Help application. PCG will complete, submit and monitor each application on behalf of the member. The service is free of charge to all Trust members. Page 25

26 Members who think they may qualify can call PCG and speak with a representative. Below is the contact information for Public Consulting Group: 5511 Capital Center Drive, Suite 550 Raleigh, NC Phone: extrahelp@pcgus.com Online: Medicare Part D High-Income Individuals If a member s income is above a certain limit, the member will pay an income-related monthly adjustment. This monthly adjustment is paid directly to Social Security and not the Trust. If Member s Yearly Income in 2015 was File Individual Tax Return File Joint Tax Return Additional Cost To Member $85,000 or less $170,000 or less None Above $85,000 up to $107,000 Above $170,000 up to $214,000 $13.30 Above $107,000 up to $160,000 Above $214,000 up to $320,000 $34.20 Above $160,000 up to $214,000 Above $320,000 up to $428,000 $55.20 Above $214,000 Above $428,000 $76.20 Frequently Requested Prescription Drugs Not Covered Proton Pump Inhibitors, also known as PPIs, are not covered for non-medicare eligible members.* PPI products include: Nexium, Prevacid, Protonix, Prilosec, Aciphex, Zegerid, lansoprazole, pantoprazole, and omeprazole A coverage review is available in cases where the member is diagnosed by their physician with Barrett s Esophagus or Zollinger-Ellison Syndrome. The physician or member can initiate a coverage review by calling Express Scripts Member Services * Select PPIs are covered for Medicare-eligible members in the Express Scripts Medicare PDP. Check current Express Scripts Medicare PDP formulary to determine if a specific drug is covered. Erectile dysfunction drugs are not covered. Erectile Dysfunction drugs include: Viagra, Cialis **, Levitra, Edex, Muse, and Caverject A coverage review for Viagra only is available in cases where the member is diagnosed by their physician with Pulmonary Arterial Hypertension. The physician or member can initiate a coverage review by calling Express Scripts Member Services ** Certain strengths of Cialis have a Medicare D approved indication. Coverage determined via a prior-authorization process. Page 26

27 Specialty Medications Specialty Medications are very high cost and have a much higher risk of discontinuation of therapy. Many Specialty Medications require special handling, storage, monitoring, and consultation requirements compared to other chemical drugs. For these reasons dispensing 90- days at one time can result in significant waste when discontinuation occurs. Express Scripts delivers medication without lapses in treatment, while limiting member and program costs when a patient cannot tolerate the medication or therapy changes early in the course of treatment. Why is a 90-day Supply Not Dispensed? A plan limit for a specific list of Specialty Medications, results in dispensing in smaller day supply increments, when obtained through mail order Over a 90-day period, the member will still receive up to a 90-day supply for the same total current mail order copay If the order is changed or discontinued, the member saves copay dollars and significant waste is avoided. Express Scripts/Accredo actively monitors and initiates/coordinates all refills with patients to ensure patient has needed medication and supplies on time Coverage for Medicare Part B Drugs Certain prescription drugs are covered by Medicare Part B and may be filled at retail or mailorder pharmacy. Plan copayments apply. Medicare Part B drugs include: Specific medications used to aid tissue acceptance from organ transplants Certain oral medications used to treat cancer Various inhalants used in nebulizers (devices that deliver liquid medication as a mist) Network retail pharmacies filling Part B prescriptions will work with the member to bill Medicare on their behalf. When using mail order, Express Scripts will work with its Medicare Part B supplier, Accredo, Express Scripts specialty pharmacy. Allergy Serums, Non-Self-Administered Injections, & Insulin/Syringes Allergy Serums are now covered under the medical benefit. All plan covered medications that are non-self-administered injections are covered under the pharmacy benefit.* *Exception: Applicable non-specialty Chemotherapy IV injections are covered under the medical benefit. In order for syringes to be covered at $0 copay, Injectable Medications and Syringes MUST BE ORDERED ON THE SAME DAY AS THE PRESCRIPTION. Page 27

28 Prescription ID Cards for Most Medical Plans Effective January 1, 2016, most Trust members (Medicare and non-medicare) will have prescription drug coverage provided by Express Scripts. (Some HMOs have prescription drug coverage through the HMO.) Medicare-Eligible Members Non-Medicare-Eligible Members Copay Reviews (Non-Medicare Members Only) Copay Reviews available effective 1/1/2011. If approved, the copay for the brand-name medication falls under Tier 2. (Based off of FDA MedWatch form that the member s doctor must submit) To initiate a Copay Review, the member calls Express Scripts at Prior Authorizations For a medication that requires a Prior Authorization, the member or prescriber can call Express Scripts at to initiate the PA case Express Scripts Appeals for non-medicare eligible members Administrative reviews and appeals are based on the plan's benefit design or conditions of coverage without additional information required from the prescriber. Clinical reviews and appeals are based on conditions of coverage and may require additional information from the prescriber. Initial Determination Coverage Review reviewed by Express Scripts o Member calls Express Scripts at to initiate the review Initial Administrative Determination Coverage Review reviewed by Express Scripts o Member calls Express Scripts customer service at , and a coverage review form is sent to the member o For an urgent administrative review, the member calls Express Scripts at Level 1 Appeal reviewed by Express Scripts Level 2 Appeal reviewed by Express Scripts Page 28

29 Address for Level 1 and Level 2 Appeals Administrative Appeals: Clinical Appeals: Express Scripts Attn: Administrative Appeals Department PO Box St. Louis, MO Express Scripts Attn: Clinical Appeals Department PO Box St. Louis, MO Voluntary Appeal* reviewed by the URMBT: UAW Retiree Medical Benefits Trust Attn: Appeals P.O. Box Detroit, MI *You must exhaust all levels of the appeal process at Express Scripts before submitting a voluntary appeal Express Scripts Appeals for Medicare-eligible members Clinical reviews are similar for the Express Scripts Medicare PDP. However, if a member s Level 1 Appeal is denied, and the member decides to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision. The Independent Review Organization is an independent organization that is hired by Medicare. Reviewers at the Independent Review Organization will take a careful look at all of the information related to the appeal. The organization will tell the member its decision in writing and explain the reasons for it. If the dollar value of the drug the member has appealed meets certain minimum levels, the member may be able to go on to additional levels of appeal. If the dollar value is less that the minimum level, the member cannot appeal any further. For a complete listing of the appeal process for the Express Scripts Medicare PDP, review Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) in the 2017 Evidence of Coverage for Express Scripts Medicare document. Trust Appeal Process If a medical or prescription drug claim is denied in whole or part, retirees have the right to file an appeal. If the claim remains denied during the appeal process at the carrier, retirees may request a Voluntary Review at the Trust. Detailed information can be found in the Summary Plan Description. If you assist a retiree in filing an appeal the Personal Health Information (PHI) Authorization Form is required. Mail appeal and PHI form to the Trust address above. The instructions and form follow. Page 29

30 Personal Health Information Authorization Instructions & Form Page 30

31 Page 31

32 Helpful Resources & Tips Things to Keep in Mind Retiree benefits are not the same as active employee benefits Advise the members that switching to pension deduction or direct debit not only saves time by automating their payment they also save the Trust additional fees in processing the paper invoice When requesting an emergency add for a participant/dependent, make sure there is truly an emergency or access to care issue (i.e. prescription/appointment needed or scheduled within 2-3 days) Encourage retirees and dependents to sign up for Medicare Parts A and B when eligible. If the member is eligible for Medicare but not enrolled, claims will still be paid as if the member is enrolled in both Medicare Parts A and B Retirees should contact Retiree Health Care Connect to change their health care plan Retirees should contact their health plan directly for claim inquiries (phone number is on back of the ID card) and Retiree Health Care Connect for eligibility issues When retirees have an eligibility issue, the first point of contact for resolution should always be Retiree Health Care Connect. If an issue needs to be escalated to the Trust, send it to Barb Fiddler to investigate. Sending the same inquiry to more than one Trust representative causes confusion and unnecessary work When you are assisting a retiree on a claim issue, a signed authorization form may be required if you are requesting specific information considered Protected Health Information. This form is not needed if you simply want a confirmation that the issue was resolved. A copy of this form is provided in the appeals section of this manual When sending s, never include any personal information, such as name or Social Security number, in the subject line of an . The message should include only the information necessary to identify the person and investigate the problem name and last four of social security number is sufficient Be aware that you may receive calls from retirees who transferred to Medicare Advantage (MA) plans. MA networks are usually smaller networks so some physicians may not be in the plan s MA network. Retirees should check to see if their physician participates in the MA plan before enrolling Page 32

33 Resources & Contact Information The following resources are available to assist in member inquires (underlined items are for UBRs only and not intended for retiree/member use) UAW Retiree Medical Benefits Trust Online The following documents above found under Trust Communications Summary Plan Description (SPD) Schedule of Benefits Benefit Highlights Quick Reference Guides (UBR Updates) Found under UBR File Cabinet in the Resources and Answers section ACS (Ford retirement packet questions) Phone: Retiree Health Care Connect (RHCC) Phone: Online: UBR Hotline: Blue Cross Blue Shield Contact for members vary by plan (see Schedule of Benefits for more information) UBR Hotline: Express Scripts (Prescription Drugs) Phone: (Press 1 at the prompt for assistance in the Express Scripts Medicare PDP) Online: Low Cost Generic Program: 877 RxSAVE-NOW ( ) UBR Hotline: AudioNet Hearing Delta Dental of Michigan Midwestern Dental SVS Vision TheraMatrix Physical Therapy Network Phone: Online: Phone: Online: Phone: Online: Phone: Online: Phone: Online: UAW Trust Contact for Ford UBRs Trust UBR Contact: Barb Fiddler Phone: Fax: bfiddler@rhac.com Ford UBR Contact at the Trust is for escalation purpose only When contacting be prepared to discuss experience and outcome of RHCC UBR Line or Plan Call Center discussions Page 33

34 Retiree Health Care Connect (RHCC) website When retirees first log onto the website it is mandatory that they register and create a unique User ID and Password. If a UBR is transacting for the retiree/member you MUST log on as the retiree/member and will need to complete the registration if 1 st time on web To register the retiree you will need last 4 of Social Security number, birth date and ZIP code Tip If setting up a user ID and password on behalf of the member for the first time, you may want to use the same protocol such as always using the retiree s last name as the user ID and last 4 digits of SSN for the password. Events Available on RHCC Website Address changes Add address Qualified Status Changes (reporting changes to dependents, deaths, etc.) Change banking information Heath care plan modeling Request forms Heath care plan modeling Request forms Page 34

35 Payroll Deductions/ Direct Billing Information Available See current bill/balance and paid through date Change personal information and preferences Request direct debit/ pension deduction Page 35

36 The Trust Website The official UAW Retiree Medical Benefits Trust website can be found at This is a public website and does not require a login. The site is designed both for the members as well as the general public who would like more information about the Trust. The site provides background history of the Trust, its mission and organizational structure, including biographies of the Board of Trustees. Member specific resources include detailed information about: Medical Benefits Prescription Drug Coverage Medicare Information Eligibility Life Events Resources, website links, and answers to common questions Archive of Communications from the Trust Videos on benefit changes and the history of the Trust Choosing Wisely Online Resources New to the Trust website in 2016 is a section dedicated to the Choosing Wisely program. Choosing Wisely is a national campaign from the American Board of Internal Medicine Foundation and Consumer Reports. Its purpose is to help consumers take a more active role in their health care. Retirees can access videos, articles and tip sheets designed to help them take a more active role in their health care. Page 36