Summary of Material Modification

Transcription

1 Summary f Material Mdificatin T: Participants Frm: Human Resurces Re: Amendment t University f the Pacific Self-Funded Medical Plan Effective January 1, 2017, the University f the Pacific has amended its self-funded medical plan t achieve cmpliance with the Affrdable Care Act (ACA) Sectin 1557 nndiscriminatin rules, add eligibility rules fr emplyees wh are nt reasnably expected t be full-time emplyees as f his r her start date (Variable Hur Emplyees), as well as reflect plan design changes t the medical and prescriptin drug benefits. This Summary f Material Mdificatin supplements r mdifies the infrmatin presented in yur Summary Plan Descriptin (SPD) with respect t the University f the Pacific Self-Funded Medical Plan (Plan). 1. ELIGIBILITY is hereby amended by adding eligibility rules fr Variable Hur Emplyee Eligibility, as fllws: Variable Hur Emplyee Eligibility An emplyee wh is nt reasnably expected t be a full-time emplyee as f his r her start date, r an emplyee wh is seasnal (in a psitin fr which the custmary annual emplyment is six mnths r less) (Variable Hur Emplyee), will be determined t be a full-time emplyee based n whether such emplyee satisfies the full-time emplyee hurly requirements under the fllwing Lk-Back Measurement Methd. Effective Date f Cverage. Eligibility cmmences n the first day f the mnth cinciding with r fllwing 13 mnths f emplyment. Determinatin f Full-Time Status under ACA Lk-Back Measurement Rules. A Variable Hur Emplyee will becme eligible fr benefits under this Plan after the emplyee wrks an average f 130 hurs per calendar mnth fr a perid f time spanning a specific number f mnths, referred t as the Measurement Perid. The University will use the Measurement Perid calculatin results t determine full-time r part-time status f the emplyee. Eligibility (full-time status achieved) r ineligibility fr benefits will last fr a specific number f cnsecutive mnths (referred t as the Stability Perid ) fllwing the Measurement Perid. Lk Back Perids Adpted by the University. Effective as f Octber 1, 2013, the University has adpted the fllwing time perids fr determining the eligibility f Variable Hur Emplyees: Initial Measurement Perid. In rder t assess hurs wrked, a newly hired Variable Hur Emplyee will be placed n an Initial Measurement Perid lasting twelve (12) cnsecutive mnths beginning n the first day f the mnth fllwing date f hire. Fllwing the Initial Measurement Perid, the University will calculate the results and, if applicable, ffer cverage t an eligible newly hired Variable Hur Emplyee during a ne-mnth perid f time set aside fr administrative purpses. Initial Stability Perid. A newly hired Variable Hur Emplyee s eligibility r ineligibility fr benefits will last fr a perid f twelve (12) cnsecutive mnths beginning n the first day f the mnth immediately fllwing the Initial Measurement Perid plus crrespnding administrative perid. Rev. 11/2016 Page 1 f 7

2 Hwever, the Initial Stability Perid fr an ineligible emplyee must be the shrter f twelve (12) mnths r the perid frm the first day f the Initial Stability Perid t the end f the Standard Measurement Perid (plus crrespnding administrative perid) in effect at that time. Standard Measurement Perid. Onging Variable Hur Emplyees wh have cmpleted the Initial Measurement Perid will be placed n the Standard Measurement Perid t reassess eligibility. This Measurement Perid lasts twelve (12) cnsecutive mnths beginning n Octber 15 f each year and ending n Octber 14 f the fllwing calendar year. Fllwing the Standard Measurement Perid, the University will calculate results and ffer cverage t any eligible nging Variable Hur Emplyees during a tw and ne half-mnth perid f time set aside fr administrative purpses. Standard Stability Perid. An nging Variable Hur Emplyee s eligibility r ineligibility fr benefits will last fr a perid f twelve (12) cnsecutive mnths beginning n January 1 f each year and ending n December 31 f the same calendar year. Calculating Hurs f Service. An hur f service refers t each hur fr which an emplyee is paid, r entitled t payment, fr the perfrmance f duties fr «Shrt_Name» within the United States, including time during which n duties are perfrmed due t vacatin, hliday, illness, incapacity (including disability), layff, jury duty, military duty, r leave f absence. In the case f hurly emplyees, the University will calculate actual hurs f service frm recrds f hurs wrked and nn-wrked hurs fr which payment is made r due (e.g., vacatin, hliday, illness, incapacity, etc.). Fr salaried emplyees, the University will calculate hurs f service using ne f the fllwing three methds: (i) actual cunting f hurs f service; (ii) using a days-wrked equivalency (i.e., eight hurs f service fr each day fr which the emplyee is entitled t pay fr wrked r nn-wrked time); r (iii) using a weeks-wrked equivalency (i.e., 40 hurs f service per week fr each week fr which the emplyee is entitled t pay fr wrked r nn-wrked time). ACA requires emplyers t use a special hurs-f-service averaging methd fr time away due t unpaid leave under FMLA, USERRA, r jury duty. Breaks in Service fr Variable Hur Emplyees. If a Variable Hur Emplyee terminates emplyment and is then rehired 26 r mre weeks after his r her date f terminatin, the emplyee will be treated as a new hire and must cmplete a new Initial Measurement Perid t determine their eligibility fr benefits. If the University determines the emplyee has been cntinuusly emplyed after the break, the measurement and stability perids that wuld have applied t the emplyee had he r she nt experienced the break in service will cntinue upn rehire. If applicable, cverage under this Plan will be restred n the first day f the mnth fllwing his r her date f rehire. Rev. 11/2016 Page 2 f 7

3 2. The BENEFITS Sectin is hereby amended by replacing the Plan Benefit chart t reflect changes t the plan design, as well as amend the Welldyne prescriptin drug plan as fllws: MEDICAL AND PRESCRIPTION DRUG PLAN BENEFIT CHOICES. The fllwing chart replacing the same chart in the SPD. These changes shall als be reflected in the Schedule f Benefits tables n Appendix B, as applicable: Plan Benefit Lifetime Maximum Calendar Year applies unless Calendar Year Out-f-Pcket Maximum Includes abve Office Visits Preventive Care Acupuncture Chirpractr Durable Medical Equipment (DME) Lab & X-Ray Preventive Lab & X-Ray PPO EPO PPO-HD Netwrk Nn-Netwrk Netwrk Nn- Netwrk Netwrk Nn- Netwrk Unlimited Unlimited Unlimited $300 Individual / $900 Family* * Family can be met with a cmbinatin f family members $1,500 Individual / $4,500 Family Nn-Netwrk des nt cmbine with Netwrk (12 visits/ year) $10 cpay (30 visits/ year) $150 Individual / $450 Family* * Family can be met with a cmbinatin f family members $4,500 Individual / $9,000 Family $1,500 Individual / $4,500 Family (12 visits/ year) (30 visits/ year) $20 cpay $20 cpay $10 cpay (30 visits/ year) ($100 cpay + per test fr MRI, CT, PET, etc.) $2,500 Individual / $5,000 Family* * If family cverage, the entire $5,000 must be met but it can be met by 1 member r a cmbinatin f the entire family unit $5,000 Individual / $10,000 Family Nn-Netwrk des nt cmbine with Netwrk (12 visits/ year) (30 visits/ year) (12 visits/ year) (30 visits/ year) Rev. 11/2016 Page 3 f 7

4 Plan Benefit Inpatient Hspital PPO EPO PPO-HD Netwrk Nn-Netwrk Netwrk Nn- Netwrk Netwrk Nn- Netwrk $250 cpay, $250 cpay, $250 cpay, then then then Outpatient f $350 f $350 Surgery max. per day max. per day Emergency Rm/Transprtatin Facility $250 cpay then $250 cpay then Physician Emergency Transprtatin Prescriptin Drugs (30 Days Retail Supply) Generic $15 cpay $15 cpay $10 cpay $10 cpay after after Cpay and 50% Brand Name $25 cpay f the full cst f the $25 cpay prescriptin Nn-Frmulary $45 cpay $45 cpay Self- Administered Injectables Cpay and 50% f the full cst f the prescriptin t max. $150 t max. $150 $30 cpay after $50 cpay after $30 cpay after $50 cpay after after is met Prescriptin Drugs (90 Days Mail Order Supply) Generic $15 cpay $15 cpay $10 cpay nce is met Brand Name $25 cpay $25 cpay $60 cpay nce is met Nn-Frmulary $45 cpay $45 cpay $100 cpay nce is met Specialty Drug Intercept Prgram (Effective 11/1/2015). The Welldyne prescriptin drug plan includes a vluntary Intercept Prgram intended t reduce specialty drug csts using financial assistance prgrams. Under the prgram, cvered medicatins may still be btained subject t satisfying all ther eligibility requirements and will be cnsidered ut f netwrk if nt btained thrugh the prgram. Out f netwrk medicatin fulfillment will result in a c-payment equal t the amunt f the assigned plan c-payment plus the value f any cupn r prgram that a participant wuld therwise have been eligible t participate in (ut f netwrk penalty). EXCLUSIONS. Exclusins nw include the fllwing prescriptin drug exclusin: Effective 8/1/2016: Under the WelldyneRX prescriptin drug plan, all new medicatins apprved by the FDA will be subject t a six-mnth exclusin perid fr frmal Pharmacy and Therapeutics cmmittee review. The exceptin t this exclusin are medicatins used fr rphan disease states and medicatins that ffer significant benefits ver existing therapies. Rev. 11/2016 Page 4 f 7

5 3. APPENDIX D is added t ntify participants f the University s cmpliance with ACA Sectin 1557 Nndiscriminatin rules, as fllws: APPENDIX D UNIVERSITY OF THE PACIFIC SELF-FUNDED MEDICAL PLAN SUMMARY PLAN DESCRIPTION Sectin 1557 Ntice f Nndiscriminatin University f the Pacific (UOP) cmplies with applicable Federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. UOP des nt exclude peple r treat them differently because f race, clr, natinal rigin, age, disability, r sex. UOP: Prvides free aids and services t peple with disabilities t cmmunicate effectively with us, such as: Teletype (TTY) Written infrmatin in ther frmats (large print, audi) Prvides free language services t peple whse primary language is nt English, such as: Qualified interpreters Infrmatin written in ther languages If yu need these services, cntact Delta Health Systems at (TTY: ) If yu believe that UOP has failed t prvide these services r discriminated in anther way n the basis f race, clr, natinal rigin, age, disability, r sex, yu can file a civil rights cmplaint with: University f the Pacific Directr f Human Resurces 3601 Pacific Avenue Stcktn, CA (209) (TTY: ) Yu can file a grievance by mail, fax, r . If yu need help filing a grievance, the Directr f Human Resurces is available t help yu. Yu can als file a grievance with the U.S. Department f Health and Human Services, Office fr Civil Rights, electrnically thrugh the Office fr Civil Rights Cmplaint Prtal, available at r by mail r phne at: U.S. Department f Health and Human Services 200 Independence Avenue, SW Rm 509F, HHH Building Rev. 11/2016 Page 5 f 7

6 Washingtn, D.C , (TDD) Cmplaint frms are available at Rev. 11/2016 Page 6 f 7

7 All ther Plan prvisins remain unchanged s lng as they are cnsistent with this mdificatin. Please keep this Summary f Material Mdificatin with yur ther grup health plan materials, EOC, r Summary Plan Descriptin. T btain mre infrmatin cntact emplyee_benefits@pacific.edu at (209) Rev. 11/2016 Page 7 f 7