2019 FAQs Medical plan. Frequently Asked Questions from employees

Transcription

1 2019 FAQs Medical plan Frequently Asked Questions from employees September 2018

2 Medical plan benefits Here are some commonly asked questions about the Medical Plan Benefits that our employees have raised. To find a particular topic, click on the subject or category below to go directly to that section of the FAQ. Medical Plan Choices Who s eligible About the Medical plans About preventive care BCBSIL medical plan covered expenses BCBSIL PPO benefits BCBSIL CDHP benefits BCBSIL online services and features Glossary of health care terms Important If there is ever a conflict in the information provided in this FAQ, the plan documents and summary plan descriptions will govern. In addition, participation in the benefits program does not constitute a right to continued employment with the Company. While it is the Company s intent to continue these programs, we reserve the right to amend or terminate any plan at any time, for any reason. 2

3 Medical plan benefits Medical plan choices Q. What are the medical plan options? Dover offers two types of medical plans: Consumer Driven Health Plan (CDHP), with cost-saving Health Savings Account (HSA) Preferred Provider Organization (PPO) Refer to your Benefits Enrollment Decision Guide for the medical choices at your Company. Q. When is annual enrollment? Annual enrollment is held each fall, and is your once-a-year chance to make new benefit elections for the coming year you can add, drop or make changes to your existing benefits, depending on your needs. For annual enrollment dates, coverage choices, plan details and more, see your Benefits Enrollment Decision Guide. Who s Eligible? Q. Who s eligible for medical coverage through Dover? You are eligible for medical coverage if you are a Dover employee regularly scheduled to work at least 30 hours per week. You can also enroll your eligible dependents. New hires should check with your local HR representative to confirm specific eligibility rules. Q. Who are considered my eligible dependents to enroll in Dover benefit plans? When you enroll for coverage, you may also be able to enroll your eligible dependents, including: Your spouse to whom you are legally married: This does not include a spouse from whom you are legally separated or divorced, even if the courts require you to provide coverage Your same- or opposite-sex domestic partner and his/her eligible children: You will be required to complete the Affidavit of Domestic Partnership and provide documentation as requested. The Affidavit will be mailed to your home after you complete your enrollment. If you have a marriage certificate for your same-sex marriage, you will not be required to complete the Affidavit nor be subject to imputed income. If your domestic partner and his/her children do not qualify as your tax dependents under Section 152 of the Internal Revenue Code, imputed income applies to the cost of their coverage. You may cover eligible children of a domestic partner only if you and your approved domestic partner are enrolled in that particular Dover benefit plan. Special rules apply if your domestic partner becomes eligible for Medicare; see your SPD or contact BCBSIL for more information Your dependent children up to age 26: Includes your natural children, stepchildren, children placed with you for adoption and children for whom you are the legal guardian Your disabled dependents over age 26 whose disability was certified while an eligible dependent under the Dover plan before age 26. If your disabled dependent is over age 26 when you are hired, he or she is not eligible to be enrolled 3

4 About the Medical Plans Q. Can you explain about the different types of medical plans offered? The two types of medical plans that Dover offers are the CDHP and the PPO. You ll find brief descriptions of each plan and how benefits are determined in this FAQ. Since it s helpful to understand certain terms when describing each plan, we ve included a Glossary of Health Care Terms in the last section of this FAQ. You can also refer to your Benefits Enrollment Decision Guide. Q. What is a Preferred Provider Organization (PPO)? The PPO is provided through Blue Cross Blue Shield of Illinois (BCBSIL) The PPO plan gives you a choice of getting in-network care or going to a provider outside of the network. When you use in-network providers and facilities, the plan pays a higher benefit level and you get the advantage of benefits paid at a discounted rate. If you use out-of-network providers, you will pay a higher deductible and coinsurance, and are responsible for amounts that exceed the plan s maximum allowable limit. The PPO also covers in-network preventive care at 100% but there is no coverage if you see an outof-network provider. The BCBSIL PPO includes prescription drug benefits through CVS Caremark, for more information about prescription drug coverage see the Prescription Drug FAQ document. Q. What is a Consumer Driven Health Plan (CDHP)? The CDHP is provided through Blue Cross Blue Shield of Illinois (BCBSIL) The CDHP has a higher deductible so that your contributions can be kept lower and the company opens an HSA account and funds quarterly. Review your HSA chart included in your enrollment materials for more information. The deductible does not apply to preventive care which is covered at 100% or certain medications determined to be preventive. If you are taking a preventive medication you do not need to meet the deductible, the applicable prescription drug copay or coinsurance would apply and be applied to your out-of-pocket maximum. To confirm if a medication is on the preventive drug list go to or call The CDHP uses the same BCBSIL provider network as the PPO; and like the PPO, pays a higher benefit if you choose in-network providers. Because you get the advantage of network discounted rates, you ll generally pay less when you get care in-network. If you use a physician who s not part of the network, the plan pays benefits at the out-of-network level, and you re responsible for amounts that exceed the plans maximum allowable limit. The CDHP also covers in-network preventive care at 100% but there is no coverage if you see an out-of-network provider. The BCBSIL CDHP includes prescription drug benefits through CVS Caremark, for more information about prescription drug coverage see the Prescription Drug FAQ document. Special HSA Savings Advantage If you enroll in the CDHP, you have the opportunity to participate in a Health Savings Account (HSA) if eligible. This tax-favored HSA lets you save money to pay for health care expenses, such as your CDHP deductible or you can keep the money in your account to use for future health care expenses. For more information about the HSA see the Health Savings Account and Flexible Spending Accounts FAQs. Q. Where can I find a list of BCBSIL network providers? To find a provider in the BCBSIL network contact customer service at or bcbsil.com/dover. Q. Are there any other options to connect with a BCBSIL provider online? Yes. Your medical plan includes virtual visits provided by MDLIVE doctors, a convenient and secure option for non-emergency health care. You can connect with a doctor through online video 24/7 for a low, flat fee for enrolled employees and spouse/partners. The option is called Telehealth and can be used for non-emergency medical events, even prescriptions, if your primary doctor is not available or you are traveling. For more information visit DoverHealthandWellness.com>Benefit Plans>Telehealth. 4

5 About Preventive Care Q. What preventive care is covered at 100%? Preventive care includes routine check-ups, screenings and patient counseling for certain medical conditions to prevent illness, disease and other health-related problems. Because preventive care is so important to your long term health and well-being, the CDHP and PPO cover in-network preventive care at 100%, with no deductible, coinsurance or copays. Preventive care is not covered if you see an out-of-network provider. Listed below are some of the preventive care services covered under the plan: Preventive Care Men Women Children Annual routine physical, and associated routine lab work Routine immunizations, vaccinations, flu shots Annual routine OB-GYN visit, Pap test Annual mammogram starting at age 40; one baseline mammogram at ages Routine immunizations, vaccinations, flu shots Routine eye exam by an ophthalmologist (not an optician) Annual preventive diagnostic tests, such as annual cholesterol screening Routine hearing screening Annual routine physical, and associated routine lab work Routine immunizations, vaccinations, flu shots Routine eye exam by an ophthalmologist (not an optician) Annual preventive diagnostic tests, such as cholesterol screening Routine hearing screening Annual routine colonoscopy, digital rectal exam starting at age 50 Annual routine prostate exam at age 50+ Annual routine physical, and associated labs and x- rays Routine immunizations, vaccinations, flu shots Routine eye exam by an ophthalmologist (not an optician) All routine well-baby visits Quick Tip Preventive vs Diagnostic Care Coding: For 100% payment for in-network preventive care, always remind your doctor or lab to code the service using the correct preventive or routine codes, generally ICD-10 Z code as the primary diagnosis. If the preventive service is coded for a diagnostic service, you will likely have to pay a deductible and coinsurance. Q. What s the difference between routine and diagnostic services? Routine means you re having no symptoms and are visiting your health care provider for an annual or check-up or screening. Diagnostic means you have symptoms or an abnormal test result or have been diagnosed with an illness or disease or medical condition. Q. I went in for a routine visit that was supposed to have no charge; why did I get a bill later? During the preventive care visit, you may have received both preventive and non-preventive care. For example during a routine physical your doctor may have treated you for another health condition that is not considered preventive and you will have to pay an additional copay, coinsurance or deductible, depending on your plan s benefits. Q. My condition requires blood tests monthly, are these tests considered preventive under the medical plan? Since monthly blood tests are for monitoring a known medical condition, they would not be considered preventive but diagnostic, and would be covered by the medical plan, subject to the deductible, coinsurance or copay. 5

6 BCBSIL Medical Plan Covered Expenses Q. Do the medical plans have annual outpatient therapy limits? Yes, there are annual outpatient therapy limits that apply to certain services, such as: Speech therapy up to 60 visits each year Occupational therapy up to 60 visits each year Physical therapy up to 60 visits each year Refer to your Summary Plan Description for details. Q. Can I take advantage of the Davis Vision Discount Program, and is it available to only to BCBSIL plan members? Yes, you need to be enrolled in a BCBSIL medical plan to take advantage of the Davis Vision Discount Program for savings on eyeglasses, contact lenses and vision correction services. You can find a list of Davis network providers by going to bcbsil.com/dover. Remember to always show your BCBSIL ID card at the Davis Vision Center to ensure you receive program discounts. Dover offers a stand-alone Vision Plan through VSP that also offers eye exams and prescription eyeglasses and contact lenses. See the separate Vision FAQ for more details or your Benefits Enrollment Decision Guide. Q. How do the BCBSIL medical plans cover out-of-network anesthesiologists or radiologists or other associated expenses during an in-network hospital stay? Generally, associated expenses during your hospital stay will be covered in-network. In many cases anesthesiologists or radiologists who work at in-network hospitals do not have a contract with BCBSIL. Since you do not have a choice of these providers during an in-network hospital stay, the medical plans will cover these expenses at the higher in-network benefit level. Q. Do deductible amounts satisfied in the fourth quarter of the year (October- December) carryover to the next year in medical plans? No. Your deductible runs between January 1 and December 31 every year. There is no carryover deductible for amounts satisfied during the fourth quarter of a calendar year. Q. The BCBSIL medical plans require that I pre-certify my hospital stay, what happens if I don t? The medical plans through BCBSIL require that you pre-certify all inpatient hospital stays (including pregnancy) and if you are admitted to certain facilities. You, your doctor or family member must call the number listed on the back of your BCBSIL ID card ( ). If you don t call BCBSIL to precertify before your admission for both non-emergency and emergency care your benefits will be reduced $350. Always call: When you know in advance about a hospital stay or care you must call at least one business day before. When it s an emergency admission or for maternity care you must call at least two business days of the start of the stay or care for: o Hospitalization o Skilled nursing facility o Home health care o Hospice care o Transport via air ambulance o Inpatient maternity care, other than for delivery if stay is extended beyond 48 hours following a vaginal delivery or less than 96 hours following a cesarean section 6

7 Q. If I have questions about my procedure, hospital stay or ongoing care, who can I contact? The BCBSIL Primary Nurse team is a resource available to you to help maximize your benefits in the event you or a covered family member faces a serious medical situation. A BCBSIL Primary Nurse will contact you if they are aware of a surgery or inpatient admission, or if they receive a call to pre-certify a hospital stay, or if a claim is submitted for a condition covered by the program. For more information contact BCBSIL at Q. Do the medical plans limit the amount of benefits paid in an individual s lifetime? Under health care reform, the medical plans cannot set an individual lifetime dollar limit on essential benefits for care, such as hospital services, maternity care and prescription drugs. However, frequency and visit limits may still apply to certain benefits, such as to physical therapy, home health care, chiropractic care and certain other benefits. For more details, refer to your Summary Plan Description. Q. How are infertility benefits covered through BCBSIL CDHP or PPO? The CDHP and PPO medical plans through BCBSIL cover infertility treatment, up to $10,000 per lifetime for medical expenses and prescription drugs combined. Services include: In-vitro fertilization Uterine embryo lavage Embryo insemination Low tubal ovum transfer Gamete intrafallopian tube transfer (GIFT) and zygote intrafallopian tube transfer (ZIFT) Note The $10,000 lifetime limit includes covered expenses while in any other Dover medical plan in which you enroll, combined; for example, if you incur treatment one year totaling $6,000 under the CDHP, then switch to the PPO the next year, you will have up to $4,000 remaining. Q. How do deductibles and out-of-pocket limits work in PPO and CDHP? The PPO and CDHP plans are designed to work differently. Keep in mind that in both the PPO and CDHP deductibles and out-of-pocket limits accumulate separately for in-network and out-of-network benefits. In the PPO, you have a medical deductible and out-of-pocket limit. There is no deductible that has to be met for prescription drug costs but there is a separate out-of-pocket limit. Your share of eligible prescription drug costs apply to a separate prescription drug out-of-pocket limit; therefore, for prescription drugs, the annual medical deductible does not have to be met before the prescription drug coinsurance or copay apply. In the CDHP, you have one deductible and out-of-pocket limit for medical care and prescription drugs costs. If enrolled in the CDHP 1400 with family coverage, the entire family deductible must be met before any benefits are paid for any family members. If you are enrolled in the CDHP 2500 with family coverage, no one person will pay more than $6,850 in-network individual deductible and the combined annual family out-of-pocket limit remains $10,000. Coinsurance and prescription drug costs apply to your annual deductible and out-of-pocket limit. If the prescription drug is listed as a preventive drug on CVS Caremark s Preventive Drug List at caremark.com/dover. The preventive prescription drug is available before the deductible is met at the regular plan copays or coinsurance. CDHP prescription drug copays apply before the plan deductible is met; therefore, copays do not apply to the deductible but will apply to the out-of-pocket limit. Please Note The PPO and CDHP medical plans includes prescription drug benefits provided by CVS Caremark, described in a separate Prescription Drug FAQ. 7

8 Q. Are BCBSIL provider and hospital networks available in every state? The BCBSIL CDHP and PPO networks are available in every state. Blue Cross Blue Shield of Illinois is the administrator of Dover CDHP and PPO medical plans, and maintains multi-state arrangements using regional physician, hospital and health care provider networks. Q. In the PPO or CDHP, do I need a referral to see my specialist? No referral is needed to see a specialist or any health care provider. However, to get the highest level of benefits and discounted rates, you ll want to find a specialist who is part of the BCBSIL network. It s easy to find BCBSIL network specialists (or providers) by visiting bcbsil.com/dover or calling BCBSIL member services at Q. I m planning to travel abroad; will my medical plan cover my claim if I need care when outside the U.S.? Yes, your BCBSIL CDHP or PPO will cover medical costs for you and your eligible dependents for care if needed while travelling outside the U.S. Before you leave home, call BlueCard Worldwide Service Center at BLUE, where you ll be provided with details about access to medical coverage while traveling outside the U.S. BCBSIL PPO Benefits Q. My network general practitioner is listed as a specialist in BCBSIL DocFinder, will I be charged the specialist copay for my office visits? The copay amount you will pay depends on the BCBSIL contracting arrangement with that particular physician. If your physician is affiliated with a multi-specialty physicians group who are employees of the group practice, you will likely be charged the specialist copay. Q. My BCBSIL PPO has a copay for doctor office visits, is that all I will pay when visiting my doctor? You will pay just the copay, unless you received additional services (like a blood test or an x-ray) so your cost may be higher. If there are any additional charges, you will likely get the bill later including an explanation of benefits (EOB) paid by BCBSIL. These additional charges are subject to your PPO deductible and coinsurance. BCBSIL CDHP Benefits Q. In the CDHP, are there copays for preventive care? No, preventive care is covered at 100% and no deductible or copays apply. Q. If I enroll in single CDHP, then later have a qualifying change in status and enroll my spouse, would the family deductible apply? When your coverage tier changes from single to family, the new (family) deductible amount would apply. Any expenses applied to the single deductible and out-of-pocket maximum prior to the change in status would carry over and apply to the family deductible and out-of-pocket maximum. For example, let s say you enroll in single CDHP 2500 during annual enrollment, then marry later and enroll your spouse starting in June. You and your spouse s combined medical and prescription expenses would first need to meet the $5,000 family deductible before the CDHP pays benefits. 8

9 Q. What if my child or spouse has Medicaid; can I enroll him or her in family CDHP and participate in an HSA? Yes. You can enroll in the CDHP with family coverage, even if your child or spouse has Medicaid. CDHP and HSA eligibility does not depend on your income, earned income, or the insurance coverage of your child or spouse. Q. Are routine eye exams considered preventive and paid at 100% in the CDHP? Yes. An annual routine eye exam is considered preventive and covered at 100% under the CDHP; no deductible or coinsurance applies. Q. How are maternity benefits reimbursed in the CDHP? Maternity care is covered just like other types of office and hospital care. Blue Cross Blue Shield contracts with in-network physicians, including obstetricians/gynecologists (OB-GYN) for discounted rates. In general, OB-GYNs bill for service after the newborn s delivery. However, it is up to the OB-GYN when you will be charged, whether by full payment at delivery or by making scheduled payments during the term of your pregnancy. Claims will be reimbursed depending how your OB-GYN decides to bill you. Q. In the CDHP, if I have a chronic condition, like high blood pressure or diabetes, that requires ongoing care and follow-up doctor visits and treatments, how are expenses reimbursed? You pay for your first medical and prescription expenses before the plan pays. Once you meet the deductible, the plan will pay a portion of the cost of covered services and you pay the coinsurance. Your deductible, coinsurance and copays count toward your out-of-pocket limit. Generally, your out-of-pocket limit is the most you ll pay in a year. Keep in mind that certain preventative drugs if on CVS Caremark s Preventive Drug List at caremark.com/dover are available before the deductible at regular copays or coinsurance. Quick HSA Savings Tip You can use Health Savings Account (HSA) tax-free dollars to help pay for your CDHP medical and prescription expenses. Q. What is a Health Savings Account (HSA)? A Health Savings Account, or HSA, is a separate account designed to help you save and pay for qualified medical and retiree health expenses on a tax-free basis. To open an HSA, you must be covered under the CDHP option and the company will open the account for you. You can use the HSA to pay for qualified medical expenses, including your CDHP deductible and out-of-pocket eligible expenses. For BCBSIL CDHP, HSA Bank administers the HSA. Refer to your Benefits Enrollment Decision Guide and separate FAQs on the HSA for more information. 9

10 BCBSIL Online Services and Features Q. How can I best access BCBSIL features and services? If you re in the CDHP or PPO through BCBSIL, you can get the most from your medical plan by going online to Blue Access for Members, where you ll find services and features that can save you time and money. CDHP and PPO medical plans through Blue Cross Blue Shield of Illinois (BCBSIL) Go online to bcbsil.com/dover (new users, click on Register Now ) or Call ; member service representatives are available Monday Friday, 7 am to 7 pm CT Going online has its advantages. To access some services, you need to log in by entering your user name and password. Check out BCBSIL Provider Finder Tool to find the provider with the lowest cost for a specific procedure as well as find a doctor, urgent care centers Review claims status and coverage details Set-up alert s to tell you when you claim is final Take advantage of Blue365 Member Discount Program for web access to health-focused discounts Q. My BCBSIL ID card shows just my name, though my family is enrolled in my medical plan, why aren t my dependents names listed? The employee member name only is shown on each BCBSIL medical ID card, even if you ve enrolled eligible family. Your coverage status will be shown as family and eligible dependents will be able to access care using the ID card with your (employee s) name. Q. I lost my BCBSIL ID card, how can I get a replacement ID? BCBSIL will mail your medical ID card to your home address within two to three weeks after you enroll. If you need a replacement card, go online to bcbsil.com/dover or call

11 Glossary of commonly used health care terms This glossary was created to help you better understand terms used by different health plans. Ancillary services Special services ordered by your physician such as laboratory, radiology, durable medical equipment, and pharmacy services. Chronic illness An illness that lasts a long time or will never be cured such as diabetes and arthritis. COBRA Stands for the federal law under which an employee and/or dependents can remain in the employer's group health plan after a qualifying event such as termination of employment or divorce. Coinsurance Your share the cost of health services provided to you by paying a percentage of the charge for the services. Copay A set dollar amount that you pay for a covered health care service. Covered services Health care services that will be paid for, in part or in full, by a medical plan. Deductible The amount of money you are required to pay each year for health care services before your health plan starts paying the bill. Keep in mind the annual deductible for in-network and out-ofnetwork (non-preferred) providers are separate. Emergency care Medical care that is needed immediately to save your life or to prevent serious harm to your health. Explanation of Benefits (EOB) After you ve visited a doctor, clinic or hospital, an EOB from your health plan administrator tells you what portion of the provider s charges are eligible for benefits and explains what s covered; or if the service is declined, will include the reasons and provide appeal information. If your provider is part of a network, you will see the discount calculated. Your EOB may be available by hardcopy or can be accessed online. Health Savings Account (HSA) An account used to pay for qualified medical services, used in with a high deductible health plan, such as Dover consumer driven health plan (CDHP). In-network A group of health care providers that form an affiliation and contract as a group with a health plan to offer negotiated rates and savings. Out-of-pocket costs Health care expenses paid by you because they are not paid or covered by the health plan. Out-of-network providers Health care providers who are not under contract with a health plan. Preferred provider organization (PPO) A network of medical providers that contracts with an insurer to provide services at pre-negotiated, discounted fees. Preventive or routine care Health care that focuses on healthy behavior and includes services that help prevent health problems. This includes health education, immunizations, early disease detection, health evaluations and routine care. Prior authorization Approval of a health care service or medication before it is provided in order for the health plan to cover the expense. Provider A person or an institution that provides health care services. 11