HEALTH BENEFIT PLAN FOR NORTHWESTERN MICHIGAN COLLEGE SCHEDULE OF MEDICAL BENEFITS AND PRESCRIPTION COVERAGE Preferred Provider Organization (PPO) High Deductible Health Plan (HDHP) Effective Date: January 1, 2014 Plan Year: The 12 month period beginning each January 1 st and ending each December 31 st. Network Benefits are provided by a network provider (except as otherwise provided by this SPD), and may require prior certification with the Benefit Administrator (except in a medical emergency). For a current status of Priority Health network providers, call the Customer Service Department at 616 956-1954 or 800 956-1954. A listing of Priority Health network providers is also available on the Internet at priorityhealth.com. Non-Network Benefits are provided by non-network providers. Services may require the satisfaction of deductibles and coinsurance amounts, and are subject to reasonable and customary charges. Some benefits must be prior certified with the Benefit Administrator (except in a medical emergency). Prior Certification: Prior certification is required for all inpatient hospital or facility services. Non-emergency admissions must be prior certified at least five working days before admission. Emergency admissions must notify the Benefit Administrator as soon as reasonably possible after admission. You or your physician must call 800 269-1260 to prior certify services. If you are receiving intensive treatment for mental health services, including inpatient hospitalization and partial hospitalization, you must notify our Behavioral Health Department as soon as possible for assistance. Call our Behavioral Health department at 616 464-8500 or 800 673-8043 for assistance. You do not need prior approval from Priority Health for hospital stays for a mother and her newborn of up to 48 hours following a vaginal delivery and 96 hours following a cesarean section. Other services requiring prior certification are: Home Health Care Hospice Care Skilled Nursing, Sub acute & Long-term Acute Facility Care Transplants Inpatient Rehabilitation Care Imaging Services Durable Medical Equipment over $1,000 Prosthetic Devices over $1,000 Certain outpatient services Clinical Trials (all stages) for Cancer or a Lifethreatening Illness/Condition The list of services that require prior certification may be updated from time to time. A current listing is available by calling the Priority Health Customer Service Department at 616 956-1954 or 800 956-1954. Other services may be prior certified by you or your provider to determine medical/clinical necessity before treatment. Prior certification is not a guarantee of coverage or a final determination of benefits under this plan. Deductibles: The deductible is the dollar amount of covered services you must incur during the plan year before benefits will be paid. The deductible is applicable to all covered services except: Routine maternity services (the deductible does apply to facility and anesthesia charges for delivery); and Preventive health care services listed in Priority Health s Preventive Health Care Guidelines that are designated to maintain an individual in optimum health and to prevent unnecessary injury, illness or disability. If you have individual coverage, you must meet the individual deductible below. If you have more than one person in your family, you have family coverage and only the family deductible applies. The family deductible can be satisfied by only one family member or by any combination of family members. The following costs do not apply towards the deductible: Services that exceed the annual day or dollar benefit maximums for a specific benefit (denied as non-covered services); penalties paid for failure to prior certify services; and costs paid by participants to provider for non-network benefits that exceed reasonable and customary. The deductible amounts renew each plan year. This plan does not carry over any deductible amounts incurred in the prior plan year. 1
Out-of-Pocket Limits: The out-of-pocket limits the total amount of covered expenses that you or your covered dependents will pay during a plan year. Once the applicable out-of-pocket limit is met, all further medical and pharmacy covered services for that benefit year will be paid at 100% of Priority Health s contracted rate for network benefits and at 100% of the lesser of billed charges or reasonable and customary charges for non-network benefits. If you have individual coverage, you must meet the individual out-of-pocket limit below. If you have more than one person on your contract, you have family coverage and only the family out-of-pocket applies. The family out-of-pocket may be satisfied by only one family member or by any combination of family members. Notwithstanding the above, the following out-of-pocket costs do not apply towards the out-of-pocket limit: Expenses for services that exceed the annual day or dollar benefit maximums for a specific benefit (denied as non-covered services); penalties paid for failure to prior certify services; and costs paid by participants to provider for non-network benefits that exceed reasonable and customary. Note: If the non-notification penalty applies, the amount Priority Health pays will be reduced even if the out-of-pocket limit has been reached. The following information is provided as a summary of benefits available under your plan. This summary is not intended as a substitute for your Summary Plan Description. It is not a binding contract. Limitations and exclusions apply to benefits listed below. A complete listing of covered services, limitations and exclusions is contained in the Summary Plan Description and any applicable amendments to the plan. BENEFITS Deductibles $1,250 per individual; $2,500 per family per plan year. deductibles) Benefit Percentage Rate 100% paid by the plan; 0% paid by the participant, unless otherwise noted. Out-of-Pocket Limits $2,750 ($1,250 deductible and $1,500 for coinsurance and copays) per individual; and $5,500 ($2,500 deductible and $3,000 for coinsurance and limits) copays) per family per plan year. Please note the deductible, coinsurance and copayments apply to the out-ofpocket limit. Maximum Individual Plan Year Not applicable. Benefit Reduction of Benefits Penalty $250 if not prior certified. (Non-Notification Penalty) Preventive Care Services - Preventive Health Care Services are described in Priority Health s Preventive Health Care Guidelines available in the member center on our web site at priorityhealth.com or you may request a copy from our Customer Service Department. Priority Health s Guidelines include preventive services required by legislation. Routine Physical Exams & Services Women s Preventive Health Services Routine Pap Smears Routine Mammograms Prostate or Rectal/Colon Cancer Screening Test Well Child Care Immunizations Routine Colonoscopies Medical Office Services Office Visits Office Surgery Office Injections Allergy Services (including allergy testing, evaluations and injections, including serum costs) 2
Medical Office Services (continued) Diagnostic Radiology, Lab and Imaging Services (Performed in physician s office or freestanding facility.) Imaging Services - Includes MRI, CAT Scans, PET Scans, CT/CTA and Nuclear Cardiac Studies (Performed in physician s office or freestanding facility.) Prior certification required. Obstetrical Services by Physician (Including prenatal and postnatal care.) $250 if not prior certified. Routine prenatal and postnatal visits are covered at 100%, deductible waived under the Preventive Health Care Services benefits above. See the Hospital Services section for facility and physician benefits related to delivery and nursery services. Not covered. Prenatal Classes Office Consultations Dietitian and Diabetic Services (other than as provided in the Priority Health s Preventive Health Care Guidelines) Education Services (other than as provided in the Priority Health s Preventive Health Care Guidelines) Hospital Services Inpatient Hospital Facility Services Prior approval is required except in emergencies or for hospital stays for a $250 if not prior certified. mother and her Newborn of up to 48 hours following a vaginal delivery and 96 hours following a cesarean section. Prior certification phone number is 800 269-1260. Inpatient Professional Charges Human Organ Tissue Transplants Covered only with prior certification from Benefit Administrator. Approved Clinical Trial Expenses (routine expenses related to approved clinical trial) Outpatient Surgical Facility Services Outpatient Hospital Professional Charges Second Surgical Opinion Pre-Admission Testing Hospital Diagnostic Laboratory & Radiology and Imaging Services Hospital Imaging Services - Includes MRI, CAT Scans, PET Scans, CT/CTA and Nuclear Cardiac Studies $250 if not prior certified. Prior certification required If the services of a surgical assistant are required for a surgical procedure, the non-network covered expenses will be the lesser of: (1) the amount charged by the assistant; or (2) 20% of the amount allowable to the physician who performed the surgery. Medical Emergency and Urgent Care Services Emergency Room Services Ambulance Services Urgent Care Facility Services 3
Behavioral Health Services - Prior certification by our Behavioral Health Department is required, except in emergencies, for inpatient services as noted below: Call 616 464-8500 or 800 673-8043. Inpatient Mental Health & Substance Abuse Services (including rehabilitation and partial $250 if not prior certified. hospitalization) Prior certification required except in emergencies. Outpatient Mental Health & Substance Abuse Services (including medication management visits) Family Planning/Infertility Services Infertility Counseling & Treatment Covered for diagnosis and treatment of underlying cause only. Limitations and exclusions apply. Vasectomy Covered only when performed in physician s office or when in connection with other covered inpatient or outpatient surgery. Tubal Ligation/Tubal Obstructive Covered at 100%, deductible waived when performed at outpatient facilities. Procedures (included as part of the Women s Preventive Health Services If received during an inpatient stay, only the services related to the tubal benefits.) ligation/tubal obstructive procedure are covered in full, deductible waived. Birth Control Services Medical Plan (i.e. doctor s office) (included as part of the Women s Preventive Health Services benefits.) Includes; diaphragms, implantables, injectables, and IUD (insertion and removal), etc. Other Services Prescription Drugs Covered prescription drugs apply to the deductible and the out-of-pocket Includes disposable needles and syringes maximum. Once the deductible is satisfied, the following copayments shall apply. for diabetics, contraceptives, sexual Once the out-of-pocket maximum is satisfied, covered prescription drugs shall be dysfunction, ADD, and certain OTC covered at 100%. drugs (see the Priority Health website for a list of approved OTC drugs). Retail Pharmacy: Excludes infertility medications, obesity Generic Drugs: $2.50 copayment medications. Brand Name Drugs: 40% copayment ($20 minimum/$40 maximum) See the Obesity benefits for possible benefits for prescription drugs. Mail Service Program (up to 90 days): Smoking cessation drugs and any Generic Drugs: $2.50 copayment medications provided in the Priority Brand Name Drugs: 40% copayment ($20 minimum/$40 maximum) Health s Preventive Health Care Guidelines, including certain women s Non-participating Pharmacy: prescribed contraceptive methods are 25% of the purchase price. covered at 100%, deductible waived. Brand-name oral and injectable contraceptives are subject to deductible and applicable prescription drug copays. Limitations apply. Durable Medical Equipment Prior authorization required for expenses over $1,000. Prosthetic & Orthotic/Support Devices Prior authorization required for expenses over $1,000. 4
Other Services (continued) Nicotine Abuse/Smoking Cessation Benefit (other than as provided in the Priority Health s Preventive Health Care Guidelines) (Includes medically necessary alternative services and over the counter products rendered in conjunction with treatment of nicotine abuse.) (Combined Network/Non-Network Smoking cessation drugs and medications are covered under the Prescription Drugs Benefit. Short-Term Rehabilitation Services Not related to Autism Treatment (Physical, Speech, Occupational, Pulmonary and Cardiac Therapy) Limitations apply. Speech therapy for developmental delay is not covered. Short-Term Rehabilitation Services Related to the Treatment of Autism Spectrum Disorder (Available for children and adolescents through the age of 18 only) Physical, Occupational and Speech Therapy; Applied Behavioral Analysis (ABA) for Autism Treatment. Chiropractic Spinal Manipulations/ Osteopathic Manipulation Therapy Services Medical necessity does not apply. Temporomandibular Joint Syndrome (TMJS) Treatment Limitations apply. Orthognathic Treatment Limitations apply. Skilled Nursing and Inpatient Rehabilitation Facilities Prior certification required. Home Health Services Prior certification required. Limitations apply. Hospice Prior certification required. Bereavement Counseling Obesity Treatment Prescription obesity drugs are not covered under the Prescription Drugs benefit, instead, these drugs may be purchased and submitted to Priority Health for reimbursement under your medical plan. Covered at 100% after deductible up to a plan year maximum benefit of $1,000 per Covered at 100% after deductible up to a benefit maximum of 68 visits per plan year. Prior Approval required for ABA. Covered at 100% after deductible up to a maximum of 24 visits per plan year per Covered at 100% after deductible up to a maximum of 60 days per plan year per Covered at 100% after deductible up to a maximum of 40 visits per plan year per Covered at 100% after deductible to a maximum benefit of $500 per family. 5
Other Services (continued) Radiation Therapy and Chemotherapy Hemodialysis Private Duty Nursing Limited to medically necessary fees of a registered nurse or licensed practical nurse. Hearing Services Covered for treatment of medical conditions and diseases of the ear only. Hearing aids are not covered. Eye Care Covered for treatment of medical conditions and diseases of the eye only. Refractive errors and vision supplies are not covered. PHCS Travel Network Benefit Submit Claims for PHCS Travel Network to: Priority Health Managed Benefits, Inc. P.O. Box 232 Grand Rapids, MI 49501-0232 Coverage Information Waiting Period Requirement Faculty Employee Requirements All Other Employees Requirements Retiree Coverage Children Pre-Existing Condition Limitation Motor Vehicle Exclusion Michigan Residents Only Motorcycle Exclusion When medical care is needed while traveling outside the Priority Health service area, benefits will be paid at the network level when you use a PHCS Provider. For current provider listing, please contact PHCS at the following: PHCS Provider Phone Line: 888 785-7427 Internet Web Site: phcs.com Employed for 30 consecutive days. Coverage effective on the 30 th day of employment. Annually contracted and working at least 50% of the full-time workload and two academic semesters per plan year. Currently employed by the college in part-time employment or full-time employment for at least 18.75 hours per week and 35 weeks per academic year. Not applicable. Covered to the end of the calendar year in which they turn age 26. Over age 26 if mentally or physically incapacitated dependent. Not applicable. Benefits are not payable under this plan for injuries received in an accident involving a motor vehicle. (See Amendment No. 1 for further information regarding this exclusion.) Benefits are not payable under this plan for the initial $20,000 of medical expenses for injuries related to a motorcycle designed for use on public highways when the driver or passenger is not wearing a helmet. (See Amendment No. 5 for further information regarding this exclusion.) In accordance with the terms and conditions of the SPD, you are entitled to covered services when these services are: A. Medically/clinically necessary; and B. Not excluded in the SPD. If you seek services when prior certification is required and you do not receive prior certification, you will be charged a penalty. You will also be responsible for services rendered that are beyond those prior certified as medically/clinically necessary. If the hospital confinement extends beyond the number of prior certified days, the additional days will not be covered unless: The extension of days is medically/clinically necessary, and Prior certification for the extension is obtained before exceeding the number of prior certified days. 6
For emergency admissions, the Benefit Administrator should be notified by the end of the next business day following the admission or as soon as reasonably possible. Coverage maximums up to a certain number of days or visits per benefit year are reached by combining either network or nonnetwork benefits up to the limit for one or the other but not both. (Example: If the network benefit is for 60 visits and the nonnetwork benefit is for 60 visits, the maximum benefit is 60 visits, not 120 visits.) 7