SUMMARY OF MATERIAL MODIFICATIONS TO THE BRADLEY UNIVERSITY EPO EMPLOYEE HEALTH BENEFIT PLAN

Transcription

1 SUMMARY OF MATERIAL MODIFICATIONS TO THE BRADLEY UNIVERSITY EPO EMPLOYEE HEALTH BENEFIT PLAN The Plan Sponsor desires to make certain changes to the Bradley University EPO Employee Health Benefit Plan (the Plan ). Consequently, the Summary Plan Description and Plan Document ( SPD ) for the Plan is hereby amended as set forth below. Effective October 1, 2010, some of the benefits, terms, conditions, limitations, and exclusions contained in your SPD will change as a result of the Patient Protection and Affordable Care Act of 2010 (PPACA). Notwithstanding any other provision of your SPD, the provisions below shall apply. In the event of a conflict between the provisions of any section of your SPD and the provisions of this summary of material modifications ( SMM ), the provisions of this SMM shall prevail. 1) Changes in Maximum Lifetime Benefit/Overall Plan Year Benefit Maximum Subsection 6.5 Maximum Lifetime Benefit located in Section 6 Summary of Medical Plan Benefits of your SPD is hereby amended as follows, effective October 1, 2010: 6.5 Maximum Lifetime Benefit / Overall Plan Year Benefit Maximum The lifetime limit on the dollar value of benefits under the Plan no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of notice of August 24, 2010, to request enrollment. For more information, contact the Plan Administrator or Claims Administrator at The overall benefit maximum per plan year for each Covered Employee or Dependent while Covered under this Plan shall be the greater of: 1) the minimum annual limit permitted by state and federal law; or 2) $2,000,000, as listed in the 2010/2011 Schedule of Benefits. 2) Changes in Morbid Obesity Surgery Benefit The Morbid Obesity Surgery benefit located in Subsection 6.8 Schedule of Covered Services in Section 6 Summary of Medical Plan Benefits of your SPD is hereby deleted, effective October 1, Exclusion #64 as contained in Subsection 6.9 Exclusions and Limitations of Coverage (under your medical plan) located in Section 6 Summary of Medical Plan Benefits of your SPD is hereby deleted in its entirety and replaced with the following paragraph, effective October 1, 2010:

2 #64. Weight or Obesity Services and Surgeries -- weight reduction therapy, supplies and services, including, but not limited to, diet programs, diet pills, tests, examinations or weight loss regimens; medical and/or surgical morbid obesity treatments, such as vertical-banded gastroplasty (gastric stapling), gastric banding, roux-en-y gastric bypass, balloon dilation, wiring of the jaw and other procedures of a similar nature. 3) Changes in Other Lifetime Benefit Maximums Coverage for temporomandibular joint dysfunction and related disorders (TMJ treatment) and wigs (for hair loss due to chemotherapy or radiation) as set forth in Subsection 6.8 Schedule of Covered Services in Section 6 Summary of Medical Plan Benefits of your SPD shall no longer be subject to lifetime dollar maximums, effective October 1, Consequently, any references in Section 6 to lifetime dollar maximums for either of these benefit categories are hereby deleted. 4) Changes in Preventive Services Benefit The following is added to the Preventive Services benefit located in Subsection 6.8 Schedule of Covered Services in Section 6 Summary of Medical Plan Benefits of your SPD, effective October 1, 2010: Preventive Services In addition to the Preventive Services listed in this section, the following services shall be covered without regard to any deductible, copayment, or coinsurance requirement that would otherwise apply: (1) evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force; (2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person involved; (3) with respect to Covered Persons who are infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; (4) with respect to Covered Persons who are women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. 5) Changes in Eyeglasses and Corrective Lenses (Vision Services) Benefit The following is added to the Eyeglasses and Corrective Lenses (Vision Services) benefit located in Subsection 6.8 Schedule of Covered Services in Section 6 Summary of Medical Plan Benefits of your SPD, effective October 1, 2010:

3 Coverage for a vision examination with either an optometrist or ophthalmologist is limited to one (1) vision examination per 24 months but, effective October 1, 2010, shall no longer be subject to maximum plan payments and will be paid at 100%. All other aspects of the eyeglasses and corrective lenses (vision services) benefit, including maximum plan payments on lenses, contacts and frames, shall remain unchanged. 6) Extension of Coverage for Dependents Notwithstanding the dependent eligibility requirements described in Subsection 4.2 of Section 4 Eligibility and Participation Requirements of your SPD, a child in your family is eligible to become a Covered Dependent if the child: 1) is under age 26, and 2) is related to you by one of the relationships listed in Section 4 of your SPD, except that a child s marital status will not be considered in determining eligibility for initial or continued coverage. Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in the Plan. Individuals may request enrollment for such children for 30 days from the date of notice of August 24, Enrollment will be effective the first day of the first plan year beginning on or after September 23, 2010 (October 1, 2010, for the Bradley University Plan). For more information contact the Plan Administrator or Claims Administrator at In addition, Subsection 4.2 Dependent Eligibility of the SPD is hereby deleted in its entirety and replaced with the following new Subsection 4.2: 4.2 Dependent Eligibility - To be eligible for enrollment under this Plan as a Dependent, an individual must: Be the lawful spouse of a Covered Employee; or Be the Domestic Partner of a Covered Employee; or Be a child of the Covered Employee or the Covered Employee s lawful spouse or Domestic Partner as follows: Children under age twenty-six (26) who are either the birth children of the Covered Employee or the Covered Employee s spouse or Domestic Partner or legally adopted by or placed for adoption with the Covered Employee or Covered Employee s spouse or Domestic Partner; Children under age twenty-six (26) for whom the Covered Employee or the Covered Employee s spouse or Domestic Partner is required to provide health care coverage pursuant to Qualified Medical Child Support as defined in ERISA 609(a); Children under age twenty-six (26) for whom the Covered Employee or the Covered Employee s spouse or Domestic Partner is the court-appointed legal guardian (proof of guardianship is required at the time of enrollment); and

4 Children twenty-six (26) or older who, except for their age, qualify as a Dependent as specified above, and who are mentally or physically incapable of earning a living and who are chiefly dependent upon the Covered Employee for support and maintenance, provided that: the onset of such incapacity occurred before age twenty-six (26), proof of such incapacity is furnished to the Plan Sponsor by the Covered Employee upon enrollment of the person as a Dependent child or at the onset of the Dependent child s incapacity prior to age twenty-six (26) and upon request thereafter. Notwithstanding the above, coverage is not provided for: any person who is also covered under this Plan as an Employee; any person who is on active duty in any military, naval, or air force of any country; any spouse of an Employee who is legally separated from the Employee, including separation from a Domestic Partner; foster children; grandchildren (unless the Covered Employee or Covered Employee s spouse or Domestic Partner is the legal guardian, and documentation has been submitted to Plan Sponsor), parents or relatives. In addition, an eligible dependent of a retiree shall only include those individuals covered by the Plan as a covered dependent prior to such retiree s retirement. In all cases, the Plan Sponsor s determination of eligibility shall be conclusive. 7) Additional Medical Plan Benefit Provisions The following provisions are added to Section 6 Summary of Medical Plan Benefits of your SPD, effective October 1, 2010, as required by Patient Protection and Affordable Care Act of 2010 (PPACA): Emergency Services Emergency Services shall be covered without the need for any prior authorization determination and without regard as to whether the health care provider furnishing such services is a participating provider. Care provided by a Non-participating Provider will be paid at no greater cost to the Covered Person as if the services were provided by a Participating Provider. Direct Access to Obstetricians and Gynecologists You do not need prior authorization from the Plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a preapproved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the Plan Administrator or Claims Administrator at Selection of a Primary Care Provider The Plan generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. Until you make this designation, the Plan will designate one for you. For

5 information on how to select a primary care provider, and for a list of the participating primary care providers, contact the Plan Administrator or Claims Administrator at ) Changes to Claims and Appeals Procedures The following provisions are added to Section 10 Claims and Appeals Procedures of your SPD, effective October 1, 2010, as required by Patient Protection and Affordable Care Act of 2010 (PPACA): Right to Appeal You have the right to appeal any decision or action taken by the Plan to deny, reduce, or terminate the provision of or payment for health care services covered under your SPD. When the Plan has denied, reduced, or terminated a requested service or payment for the service based on a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service, you have the right to have the decision reviewed by an independent review organization not associated with the Plan. Except where a Covered Person s life or health would be seriously jeopardized, you must first exhaust the internal grievance process as set forth within the SPD before the Plan will grant your request for an external independent review. Your appeal rights are outlined within the SPD. In no event shall your right to appeal an action taken by the Plan, based on a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service, be any more restrictive than that set forth within Section 45 of the Illinois Managed Care Reform and Patient Rights Act [215 ILCS 134/45] and the Illinois Health Carrier External Review Act [215 ILCS 180]. All other provisions of the Summary Plan Description remain unchanged. The above changes become effective October 1, 2010 unless otherwise noted.