Health Care Benefits Handbook For HI, BCC & PEG Associates Effective January 1, 2013 Choose Well. Live Well
Welcome...1 About This Handbook...3 About the Health Care Benefit Plans...3 Updated Information...4 About Your Employment...4 If You Have Questions...5 If You Need Help Understanding This Plan Document...5 Benefits at a Glance...7 Participating in the Health Care Plans...7 Medical Plans...10 Dental PPO Plan...11 Vision Care Plan...12 What Happens If...13 If I Get Married...13 If I Divorce...13 If I Become a Parent...14 If My Child Turns Age 26...14 If My Child Is No Longer Eligible...15 If I Become Disabled...15 If I End My Employment...16 If I Die...16 Participating in Health Care Coverage...17 Who Is Eligible...17 Proof of Status...18 How and When to Enroll...19 Enrolling When First Eligible...20 Enrolling During Open Enrollment...20 Enrolling During the Year...20 Making Changes or Changing Your Coverage...22 What Coverage Costs...22 When Coverage Begins...23 What Happens If You Have Other Coverage (Coordination of Benefits)...24 Which Plan Pays First...24 How Much the Plan Pays...26 Subrogation and Reimbursement...26 Overpayment...27 When Coverage Ends...27 i
How to Continue Coverage...28 If You Take an FMLA Leave...28 If You Take a Uniformed Services Leave...29 Medical Coverage...31 Your Medical Plan Choices...31 Your Medical Options at a Glance...33 Using the PPO Plans...41 Network Providers...42 How to Pay for Your Care...43 Using the Consumer Choice Plans...49 Network Providers...50 How to Pay for Your Care...52 Other Features of the Medical Plans...57 Precertification...57 Retrospective Review...60 Case Management...61 Knowing What Is Covered and What Is Not...61 Medical Necessity...61 Eligible Expenses...62 Ineligible Expenses...76 How to File a Claim...80 Claim-Filing Deadline...80 Prescription Drug Coverage...81 How Your Prescription Drug Benefits Work...81 Your Prescription Drug Benefits at a Glance...82 How to Use Your Prescription Drug Benefits...83 In-Network Retail Pharmacies...83 CVS Caremark Mail Service Pharmacy...83 How to Pay for Prescription Drugs...85 How Prior Authorization Works...85 Knowing What Is Covered and What Is Not...86 Filing Claims...88 Claim-Filing Deadline...88 Dental Coverage...89 How the Dental PPO Plan Works...89 Your Dental Benefits at a Glance...90 Using the Dental PPO Plan...91 Preferred Dentists...91 Out-of-Network Dentists...91 ii
If Your Dependent Lives Away from Home...92 Paying for Your Care...92 Deductible...92 Coinsurance...93 Annual Benefit Maximum...94 Orthodontia Lifetime Maximum...94 An Example of How the Dental PPO Plan Works...95 Other Features of the Dental PPO Plan...95 Predetermination of Benefits...96 Alternate Benefits...96 Knowing What Is Covered and What Is Not...97 Eligible Expenses...97 Ineligible Expenses...99 Services and Supplies...100 Dental Benefits After Coverage Ends...101 How to File a Claim...102 Claim-Filing Deadline...102 Vision Coverage...103 How the Vision Care Plan Works...103 Your Vision Benefits at a Glance...104 Using the Vision Care Plan...105 In-Network Providers...105 Out-of-Network Providers...106 If Your Dependent Lives Away from Home...106 Paying for Your Care...106 Copay...106 Maximum Reimbursement Amount...106 An Example of How the Vision Care Plan Works...107 Knowing What Is Covered and What Is Not...108 Eligible Expenses...108 Ineligible Expenses...109 How to File a Claim...110 Claim-Filing Deadline...110 Continuing Coverage...111 COBRA...111 COBRA at a Glance...112 Who Is Eligible for COBRA...113 Enrolling for COBRA Coverage...115 Cost of COBRA Coverage...116 iii
Length of COBRA Coverage...116 Additional Qualifying Events...118 Special Rules for Disability...119 Early Termination of COBRA Coverage...120 Contacting the COBRA Administrator...120 Extended Health Care Coverage...121 Extended Health Care Coverage at a Glance...122 Who Is Eligible for Extended Health Care Coverage...123 Enrolling for Extended Health Care Coverage...123 Cost of Coverage...124 Length of Extended Health Care Coverage...124 Early Termination of Extended Health Care Coverage...124 Contacting the Extended Health Care Administrator...125 Rules, Regulations, and Administrative Information...127 Plan Documents...127 Your Rights Under the Employee Retirement Income Security Act of 1974 (ERISA)...127 Request for Eligibility Determination...130 Benefit Claims...130 Claims Review and Appeals Procedures...131 Health Care Plans...133 Non-assignment of Benefits...142 Determining Payment of Benefits...143 Correcting Mistakes in Payments...143 Subrogation and Right of Recovery...143 Subrogation...143 Right of Recovery...145 Your HIPAA Privacy and Security Rights...145 Participating Associate Groups...148 Change or Termination of the Plan...148 Employment Rights Not Implied...149 Other Plan Details...149 Glossary...151 Contact Information...173 iv
Welcome to the Hillenbrand, Inc. Health Care Benefits Plan Document. Looking for information about your Company health care benefits? Then you have come to the right place. The Hillenbrand, Inc. Health Care Benefits Plan Document is the first place you should turn when you have questions about your benefits. This Plan Document is the official plan document for the Company s health care benefit plans, which are components of the Hillenbrand, Inc. Welfare Plan. It also serves as the summary plan description (SPD) of the health care plans, which is required by federal law. The Company reserves the right to amend, change, or terminate the plans, programs, and policies described in this Plan Document. This Plan Document governs the following health care benefits: If you are looking for an overview of your benefits, check out Benefits at a Glance. It briefly explains who is eligible for coverage, when coverage begins, and the benefits available to you as a Company associate. Medical and prescription drug coverage Dental coverage Vision coverage However, vision coverage is also governed by an insurance contract between the Company and Fidelity Security Life Insurance Company. If you cannot find the information you are looking for in this Plan Document, refer to Contact Information for important phone numbers and websites. Or, contact the Hillenbrand, Inc. Benefits Center with any questions you may have. 1
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