GUIDE TO MEDICAL AND DENTAL PLANS

Transcription

1 GUIDE TO MEDICAL AND DENTAL PLANS B e n e f i t s e f f e c t i v e J u l y 1, t h r o u g h J u n e 3 0, Choosing your benefits is an important decision. This guide provides you with the information that will help you make an informed choice about your medical and dental coverage for the coming year. The options you choose will remain in effect from through June 30, Each spring, you have an opportunity to review your choices and make any changes you may need for the next plan year. Your Medical Plan Options: For the Open Access Plus Plan, in-network, and for the Network Plan, the plan pays the percentages shown in the chart below of covered contracted amounts. For the Open Access Plus Plan, out-of-network, the plan pays the percentages shown in the chart below of reasonable and customary charges.* You pay any copay amount, your coinsurance amount, and, for Open Access Plus, any out-of-network charges above reasonable and customary charges. * Reasonable and customary rates are used industry wide and are determined by the average range of charges made by most physicians, hospitals and other providers of care in the same geographical area. MEDICAL PLAN OPTIONS Plan Deductible (Per covered family member) Employee Only Employee + Dependent Employee + Family Plan Out-of-pocket Limit (per covered family member; includes deductible) Employee Only Employee + Dependent Employee + Family $500 $1,000 $1,000 (maximum) Open Access Plus Plan $700 $1,400 $1,400 (maximum) Network Plan only $1,800 $3,600 $3,600 (maximum) $3,600 $7,200 $7,200 (maximum) Lifetime Maximum Benefits Unlimited Unlimited Hospital inpatient and outpatient after $250 copay inpatient after $100 copay outpatient Surgeon s Charges Doctor s Visits Primary Care Physician Visit Specialist Visit after $40 copay None after $40 copay Note: Open Access Plus reimbursement as an office visit or outpatient facility visit depends on the provider s billing procedures and administration

2 MEDICAL PLAN OPTIONS continued Precertification and Review Required for inpatient care and outpatient procedures X-ray and Lab (including diagnostic testing) Preventive Services as determined by your doctor, including: Preventive Physical Exams Well Woman Exams, including related tests at physician s office Screening Tests, such as diabetes and cholesterol tests Well Child Care Open Access Plus Plan Patient is responsible for contacting CIGNA prior to obtaining inpatient care or outpatient procedures. Failure to call CIGNA will result in a 50% reduction in benefits payable. Network Plan only 1 after $25 or $40 copay per office visit or exam (no deductible) Copay applies when an office visit is billed not to charges for tests. after $25 or $40 copay per visit Immunizations 2 Mammograms, PSA, PAP Smear, Colonoscopy Preventive Diagnostic Maternity Care Pre & Post Natal Exams Delivery - Facility Charge Delivery Surgeon 3 65%after deductible 3 after $250 copay Emergency Hospital Care after $100 copay (waived if admitted) Skilled Nursing Facility, Rehabilitation Hospital and Subacute Facilities (semi - private room) (120 days combined maximum per plan year) (60 days combined maximum per plan year) Home Health Care (120 visits per plan year) (120 visits per plan year) Durable Medical Equipment ; no maximum. External Prosthetic Appliances after $200 per plan year deductible Second Surgical Opinion Voluntary, no charge; requires Voluntary, no charge; deductible waived referral from PCP Claim forms Not required Required Not required Pre-existing Condition No pre-existing condition limit applies. No pre-existing condition limit applies. 1 If part of a physician s office visit, after PCP or specialist copay. 2 Exclusions may apply for travel immunizations. 3 For the initial office visit to confirm pregnancy, plan pays after PCP or specialist copay

3 MEDICAL PLAN OPTIONS continued Open Access Plus Plan Network Plan only Mental Illness & Substance Abuse Services Annual Deductible Deductible Combined with Medical Benefits Lifetime Maximum Benefits Inpatient Care $500 Individual $1,000 Family maximum Benefits same as any other illness $700 Individual $1,400 Family maximum None No maximum No maximum No maximum after $250 copay Outpatient Care Individual therapy, group therapy (mental health only) and intensive outpatient services Physician s office visit Outpatient facility Pre-certification and Review Required for inpatient care and outpatient procedures Patient is responsible for contacting CIGNA prior to obtaining inpatient care or outpatient procedures. Failure to call CIGNA will result in a 50% reduction in benefits payable. VISION BENEFITS If you participate in the Network Plan, you receive modest vision benefits at no additional cost to you. These benefits are being administered separately by Cigna starting July 1, A summary of these benefits and information on finding network vision providers is available on the Human Resources website (see the Cigna summary of vision benefits for Network Plan participants) or by contacting Human Resources Benefits by phone ( ) or (benefits@artic.edu). There are no vision benefits in the Open Access Plus Plan. All employees, even those who receive vision benefits through enrollment in the Network Plan, may enroll in the EyeMed Vision Plan. A summary of these benefits is available on the Human Resources website (see the EyeMed Vision Plan summary) or by contacting Human Resources Benefits by phone ( ) or (benefits@artic.edu)

4 Important The Open Access Plus Plan and Network Plan will pay benefits only for treatment that is medically necessary, unless it is specifically named as a covered service. Neither the Open Access Plus Plan nor the Network Plan will pay benefits for the following: Medically unnecessary supplies, care, treatment, or surgery Expenses for or in connection with a work-related injury Any procedure or treatment that is deemed to be experimental, investigational or unproven Hearing aids Routine foot care Massage therapy Acupuncture (unless medically necessary, up to 15 visits per condition) Cosmetic surgery and therapies Note: This is not a complete list of all covered services and exclusions. See your Summary Plan Description for a more detailed list or call CIGNA at 800.CIGNA24. PRESCRIPTION DRUG BENEFITS When you enroll in one of the medical plan options, you automatically receive prescription drug benefits through Express Scripts. There is no deductible to meet for prescription drugs. To view the list of preferred (also referred to as formulary) brand name drugs, visit the Prescription Drugs Retail (not to exceed a 30-day supply) Generic Drugs Preferred Brand Drugs Non-preferred Brand Drugs Mail Order (up to a 90-day supply) Generic Drugs Preferred Brand Drugs Non-preferred Brand Drugs Both Open Access Plus and Network Plans Participating pharmacy after $10 copay after $30 copay after $50 copay Non-participating pharmacy* 50% after $10 copay 50% after $30 copay 50% after $50 copay If your doctor approves a generic drug and you choose instead to buy the brand name drug, you will also pay the difference between the price of the drug you choose and the generic equivalent. after $20 copay after $60 copay after $100 copay * The plan pays 50% of the amount a participating pharmacy would charge after the copay

5 DENTAL BENEFIT OPTIONS Plan Deductible 2 (per covered family member) Employee Only Employee + Dependent Employee + Family $50 $100 $150 (maximum) Dental PPO 1 Core Network $100 $200 $300 (maximum) Dental HMO Annual Maximum Benefit $1,500 per person None Diagnostic/Preventive Oral Exams (limits apply) Routine Cleanings (limits apply) X-rays (limits apply) Basic Restorative Fillings Extractions Root Canal Therapy Oral Surgery Periodontics Major Restorative Full and Partial Dentures Crowns and Bridges Implant Implant Prosthetic 80% after deductible 60% after deductible 50% after deductible 40% after deductible Orthodontia Children & Adults Not Covered $0 $0 $0 Various copays (see patient charge schedule available on the Human Resources Web site or from Human Resources Benefits). Claim Forms Not required Required Not required Emergency Care $66 patient charge for office visit after regularly scheduled hours In area: Contact Dental HMO personal dentist or call CIGNA24. Out of area: Seek treatment from any dentist. Contact Cigna Dental HMO regarding possible reimbursement. 1 Under the Dental PPO option, benefits for out-of-network services are based on reasonable and customary charges. Amounts determined to be above reasonable and customary are not eligible for coverage. 2 A deductible does not apply to charges reimbursed at. This Guide provides a description of the benefit programs that are effective July 1, 2014 June 30, 2015 for eligible employees of the Art Institute of Chicago. Plan provisions are described in more detail in other communications and are governed by the actual plan documents. The Art Institute of Chicago reserves the right to terminate or change benefit plans at any time, and has sole discretion to interpret the plans to determine eligibility for participation and benefits

6 TERMS YOU SHOULD KNOW ANNUAL DEDUCTIBLE 1 The amount of covered expenses that you must pay each year before your plan begins paying benefits. Each covered person in your family has a separate annual deductible. The most you can be charged, however, is the family deductible amount. ANNUAL OUT-OF-POCKET LIMIT 1 The maximum you are required to pay in any plan year for eligible medical expenses, including deductibles and coinsurance. Once you reach the annual out-of-pocket limit, your medical plan pays of all covered, eligible charges through the end of the plan year. Note: Copays, non-compliance penalties, and charges in excess of reasonable and customary charges do not count towards meeting the out-of-pocket limit. In addition, you continue to pay these expenses after you meet the out-of-pocket limit. COINSURANCE The portion of a covered expense that you pay after the plan pays its portion and after you ve met the deductible. COPAY The fixed dollar amount you pay for prescriptions and services, such as doctor office visits. EXPLANATION OF BENEFITS (EOB) An Explanation of Benefits, or EOB, is the statement you receive after you file a claim with an insurance carrier or a claim has been filed on your behalf by the doctor. This statement is a summary of the action taken on your claim how much of the bill was paid by the insurance carrier and how much is your responsibility to pay (you may already have paid that portion at the time of service). You do not receive EOBs for the Network Plan or the Dental HMO. INPATIENT HOSPITAL/OUTPATIENT PROCEDURES PRECERTIFICATION For out-of-network services under the Open Access Plus Plan, advance notice to CIGNA for admissions and services that require approval prior to when services are obtained. Failure to obtain precertification results in a reduction of benefits payable. PREFERRED BRAND A list of prescription drugs determined by the prescription drug management company to be among the best options for treating a particular condition in terms of effectiveness and cost. PRIMARY CARE PHYSICIAN (PCP) - NetworkPlan For Network Plan participants, the primary doctor who provides basic medical care and referrals to specialists. Each family member may have a different PCP. For a child, you may designate a pediatrician as the PCP. You do not need prior authorization from your PCP to obtain access to obstetrical or gynecological care but you must use a Network provider. You may change your PCP at any time during the year by calling CIGNA at 800.CIGNA24 or by logging on to my CIGNA.com. 1 For Open Access Plus, deductibles and out-of-pocket limits cross-accumulate between in- and out-of-network. Copays do not count toward the deductible