Benefit Facts Guide - City of Port Neches

TML Intergovernmental Employee Benefits Pool
Benefit Facts Guide
2011-2012
Take charge of your health with TML IEBP
Revised October 2011
BENEFIT FACTS GUIDE PLAN YEAR 2011­2012 TML Intergovernmental Employee Benefits Pool 1821 Rutherford Lane, Suite 300 Austin, Texas 78754‐5151 Phone (512) 719‐6500 Benefit Facts Guide (Rev 8‐30‐11) 1 | Page TABLE OF CONTENTS BENEFIT OVERVIEW (MAXIMIZE HEALTH ‐ MINIMIZE COST) ........................................................................................... 4 UNDERSTANDING YOUR HEALTHCARE BENEFIT OPTIONS ................................................................................................................... 4 CALENDAR YEAR PREVENTIVE/ROUTINE CARE BENEFIT (CALENDAR YEAR WELLNESS BENEFITS EFFECTIVE 1‐1‐2012) .................................. 4 COVERED INDIVIDUAL FINANCIAL LIABILITY ................................................................................................................... 6 DEDUCTIBLE ............................................................................................................................................................................. 6 OUT OF POCKET ........................................................................................................................................................................ 6 BENEFIT PERCENTAGE ................................................................................................................................................................ 6 USUAL AND REASONABLE CHARGES .............................................................................................................................................. 6 UNDERSTANDING YOUR EXPLANATION OF BENEFITS ......................................................................................................................... 7 PRESCRIPTION SCHEDULE OF BENEFITS .......................................................................................................................... 8 RESTAT MEMBERREPORTAL: FREQUENTLY ASKED QUESTIONS ..................................................................................... 16 MEMBERREPORTAL WILL ALLOW YOU TO: ................................................................................................................................... 16 HOW DO I ACCESS MEMBERREPORTAL?...................................................................................................................................... 16 CAN I ACCESS INFORMATION FOR ALL OF MY FAMILY MEMBERS? ....................................................................................................... 16 WHO DO I CONTACT IF I AM HAVING PROBLEMS USING MEMBERREPORTAL? ..................................................................................... 17 WHAT HAPPENS IF I FORGET MY USER ID OR PASSWORD? ............................................................................................................... 17 HOW DO I CHANGE MY PASSWORD? ........................................................................................................................................... 17 WHAT TYPE OF INFORMATION DOES MEMBERREPORTAL OFFER? ..................................................................................................... 17 MEDICAL CARE MANAGEMENT FEATURES ................................................................................................................... 18 HOW THE NOTIFICATION PROCESS WORKS .................................................................................................................................. 18 TAKE CHARGE OF YOUR HEALTH .................................................................................................................................. 22 INTERNAL AND EXTERNAL APPEAL OPTIONS ................................................................................................................ 22 APPEALS ................................................................................................................................................................................ 22 PRE‐EXISTING CONDITION LIMITATIONS ...................................................................................................................... 25 EXCEPTION TO THE PRE‐EXISTING CONDITION LIMITATIONS ............................................................................................................. 25 GENERAL EXCLUSIONS OR LIMITATIONS ...................................................................................................................... 26 ELIGIBILITY AND COVERAGE ........................................................................................................................................ 29 ENROLLMENT REQUIREMENTS ................................................................................................................................................... 29 EMPLOYEE ............................................................................................................................................................................. 29 RETIREE ................................................................................................................................................................................. 29 DEPENDENT ........................................................................................................................................................................... 29 ACTIVE DUTY RESERVISTS ......................................................................................................................................................... 30 NEWBORN CHILDREN ............................................................................................................................................................... 30 LATE ENTRANTS/OPEN ENROLLMENT .......................................................................................................................................... 30 OTHER ISSUES AFFECTING ELIGIBILITY AND COVERAGE ................................................................................................................... 31 CONTINUATION OF COVERAGE (COC) RIGHTS UNDER COBRA ...................................................................................... 32 PLAN CONTACT INFORMATION ................................................................................................................................................... 34 COVERAGE PERIOD MEASURED FROM QUALIFYING EVENT DATE ................................................................................. 35 CONSUMER DIRECTED PLANS ...................................................................................................................................... 36 GOVERNMENT PROGRAMS ......................................................................................................................................... 40 OTHER PRIVATE INSURANCE ........................................................................................................................................ 42 STEPS TO DECIDE BEST MEDICARE OPTION .................................................................................................................. 42 Benefit Facts Guide (Rev 8‐30‐11) 2 | Page MEDICARE ELIGIBILITY, ENROLLMENT AND ENTITLEMENT ........................................................................................... 43 PROVIDER NETWORK OVERVIEW ................................................................................................................................. 49 NOTIFICATION REQUIREMENTS FOR OPTIONS PPO, CHOICE PLUS AND OUT OF NETWORK PROVIDERS ........................ 55 NOTIFICATION REQUIREMENTS .................................................................................................................................................. 55 PRIVACY OF YOUR HEALTH INFORMATION .................................................................................................................. 57 SECURITY OF YOUR HEALTH INFORMATION ................................................................................................................. 57 DEFINITIONS ............................................................................................................................................................... 58 HELPFUL LINKS AND PHONE NUMBERS ........................................................................................................................ 66 Benefit Facts Guide (Rev 8‐30‐11) 3 | Page BENEFIT OVERVIEW (Maximize Health ‐ Minimize Cost) Understanding Your Healthcare Benefit Options •
Healthy Initiatives o Biometric Screenings o Health Power Assessment Preferred Lab Program Covered Individual Financial Liability Prescription Options Personal Health Engagement o Notification Requirements o Concurrent Review o Discharge Plan o Intensive Care Management o Predetermination of Medical Benefits •
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o Population Management o Outcome Management Benefit Limitations o
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Benefit Exclusions Eligibility and Coverage Continuation of Coverage Consumer Driven Benefit Plans Medicare Overview Preferred Provider Network Privacy/Security of Your Health Information Calendar Year Preventive/Routine Care Benefit (Calendar Year Wellness Benefits Effective 1‐1‐2012) The following will be processed for network reimbursement at 100% of network allowable and will not accumulate to the $500 calendar year maximum per the age and gender criteria. Non network provider eligible billings will be subject to usual and reasonable charges and are subject to the non network deductible and benefit percentage and will accumulate toward the $500 calendar year maximum. To be considered as an eligible preventive/routine care benefit, the provider’s bill must designate or outline a routine diagnosis code. Health Power Assessment The Health Power Assessment is an assessment tool which assists in identifying areas of focus for personal health engagement actions. Access your Personal Health Record and Health Power Assessment by signing in at www.tmliebp.org and selecting the Web Wellness Portal link under Healthy Initiatives. 1.
Heart Rate: 60‐80 beats/minute 2.
Blood Pressure: Normal <120/80; Prehypertension 120‐139/80‐89; Hypertension Stage 1 140‐159/90‐99; Hypertension Stage 2 >159/99 Body Mass Index (BMI): 19%‐24% 3.
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Lipid Profile Cholesterol: Desirable <200; Borderline High 200‐239; High >240; Total Cholesterol Ratio (TC/HDL): <= 4.5 LDL Cholesterol (Bad): Optimal <100; Near Optimal 100‐129; Borderline High 130‐159; High 160‐189; Very High >189 HDL Cholesterol (Good): Low 40; Desirable 40‐59; High >59
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Triglycerides: Normal <150; Borderline high 150‐199; High 200‐499; Very High >500
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Comprehensive Metabolic Blood Panel: Glucose, Calcium, Sodium, Potassium, CO2, Chloride, Urea Nitrogen BUN, Creatinine, Albumin, Bilirubin, Phosphatase Alkaline, Protein, Transferase Alanine Amino (ALT)(SGPT), Transferase, Aspartate Amino (AST)(SGOT) Thyroid Stimulating Hormone (TSH): Women >= age 36; tests the thyroid gland for over/under thyroid
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10. Osteoporosis Screening/Bone Density: Women >= age 51
11. Mammogram: Women >= age 40; one (1) Per Calendar Year
12. Well Woman Check Up/PAP: Women >= age 36 and < age 51; one (1) Per Calendar Year 13. Prostate Specific Antigen (PSA): Men >= age 51; tests for prostate cancer and benign prostate enlargement
14. Fecal Occult Blood Test: >= age 40 Benefit Facts Guide (Rev 8‐30‐11) 4 | Page Annual Exam Benefit The following network eligible immunizations and administrative fees are reimbursable at 100% of the allowable and are not subject to the deductible or benefit percentage and will not accumulate toward the $500 calendar year maximum. Non network eligible billings will be subject to usual and reasonable charges and are subject to the non network deductible and benefit percentage and will accumulate toward the $500 calendar year maximum. Allergy injections and expenses related to routine newborn care are not considered as part of this benefit. To be considered under this benefit, the provider’s bill must designate a routine diagnosis code. This list is a guideline, not an inclusive list. •
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Mammogram (one (1) per calendar year) PAP Screening (one (1) per calendar year) PSA (Prostate Specific Antigen test) (one (1) per calendar year) •
Colon‐Rectal examination ‐ Coverage for medically‐recognized screening examination for the detection of colorectal cancer for covered individuals who are fifty (50) years of age or older or for covered individuals who are less than fifty (<50) years of age that have a family or personal history and at normal risk for developing colon polyps or colon cancer for Eligible Benefits incurred while conducting a medically‐recognized screening examination for the detection of colorectal cancer. This includes: h
annual fecal occult blood tests and a colonoscopy (performed every ten (10) years); and/or h
flexible sigmoidoscopy (examination of the large intestine) performed every five (5) years with a family or personal history of colon polyps, colon cancer. This Benefit excludes coverage for virtual colonoscopies. This benefit will include routine and diagnostic colon‐rectal examinations. The following preventive/routine care benefits will accumulate toward the $500 calendar year maximum. This list is a guideline, not an inclusive list. •
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General Health Panel TB test Chest X‐Ray (front & lateral) EKG (electrocardiogram) Well Baby Care/Well Child Care Diagnostic genetic testing Carotid Screening Immunizations The following immunizations and administrative fees are reimbursable at 100% of allowable, subject to usual and reasonable charges, and are not subject to the deductible or benefit percentage and will not accumulate toward the $500 calendar year maximum. Allergy injections and expenses related to routine newborn care are not considered as part of this benefit. To be considered under this benefit, the provider’s bill must designate a routine diagnosis code. This list is a guideline, not an inclusive list. Immunizations/Inoculations •
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DT (Diphtheria and Tetanus Toxoids) DtaP Diphtheria, Tetanus Toxoids and Pertussis Td (Tetanus) booster MMR (Measles, Mumps, Rubella) MMR booster Poliomyelitis Vaccine Oral Polio Varicella Vaccine (Chicken Pox) Influenza Hepatitis A Hepatitis B •
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Pneumococcal (Pneumonia) Pediarix (Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine Combined) HIB (Hemophilus Influenza B) HPV (Genital Human Papillomavirus) Rotovirus Zosatavax (Shingles Vaccine) Any other immunization required by federal or state law or regulation Benefit Facts Guide (Rev 8‐30‐11) 5 | Page COVERED INDIVIDUAL FINANCIAL LIABILITY Your Payment Responsibility Deductible What is my deductible? The deductible is the amount you must pay for eligible charges incurred each calendar year before the plan pays any benefits. The deductible you pay starts over January 1st of each year. The Family Deductible is a cumulative dollar amount and applies collectively to all covered family individuals. Once the family deductible is satisfied, no further deductible requirements will be applied for any covered family individual within the calendar year. For a confinement that continues into a new calendar year, amounts applied toward the prior calendar year deductible will also count toward the next calendar year deductible for charges during that confinement. All other charges are subject to the new calendar year deductible. The family deductible is calculated using two covered individual deductible amounts. If the deductible amount changes in the middle of a calendar year, the deductible increase will have to be met prior to the plan benefit percentage being applied. The midyear deductible change will be renewed calendar year thereafter. The deductible is an additional out of pocket cost to the out of pocket maximum amount. Out of Pocket What is my Out of Pocket? Each calendar year, after the deductible has been satisfied, your medical benefit plan pays a benefit percentage of eligible expenses and you pay a percentage up to a maximum Out of Pocket amount. This dollar amount is the Out of Pocket maximum. Once you have paid the deductible amount and Out of Pocket maximum, the plan pays 100% of the eligible charges incurred during the rest of the calendar year. If you are in the hospital on December 31st, remain in the hospital and have met the Out of Pocket maximum, the plan will pay 100% of eligible charges for that confinement. The Family Out of Pocket is a cumulative dollar amount and applies collectively to all covered family individuals. Once the family out of pocket is satisfied, no further out of pocket requirements will be applied for any covered family individual during the remainder of the calendar year. If the out of pocket expense changes in the middle of a calendar year, the out of pocket expense increase would have to be met prior to the benefit percentage paying at 100%. Benefit Percentage What is the plan benefit percentage? Your Schedule of Medical Benefits contains the plan benefit percentage. It is the percentage that the plan pays for eligible expenses after you have paid the deductible, emergency room access fee or office visit copay. Exclusion: A health condition or circumstance not eligible for coverage under your health plan. What your plan doesn’t cover is listed in the Healthplan Booklet for your benefits. Call you plan’s customer service number to get a copy of the excluded benefits. Usual and Reasonable Charges What are usual and reasonable charges? The plan will pay the benefit percentage for eligible charges up to the usual and reasonable rate and average wholesale pricing as defined by the Plan Document and determined by the Pool. A usual and reasonable charge is deemed to be 110% of the amount prescribed by the Centers for Medicare and Medicaid Services (CMS), RBRVS, other specialty CMS fee schedules and the Ingenix Essential RBRVS Fee Schedule. Charges above the usual and reasonable amount are not paid by the plan and are your responsibility. The amount you pay for eligible charges that are above usual and reasonable amount does not apply to satisfying the deductible or Out of Pocket maximum. Eligible Prescriptions, if purchased through the medical plan, are subject to Average Wholesale Pricing, Average Sales Price or usual and reasonable charges. Benefit Facts Guide (Rev 8‐30‐11) 6 | Page Emergency Room (ER) A $100 access fee is charged for an Emergency Room visit. The access fee does not apply toward the deductible or Out of Pocket maximum. The remaining balance for the ER visit is paid at the plan benefit percentage and is subject to the deductible. Understanding Your Explanation of Benefits 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Date of Service ‐ Date the service was incurred. Total Charge ‐ The amount your provider is charging for services. Ineligible ‐ Any amounts listed in this column may not be covered under the terms of your benefit plan and may be your responsibility to pay. For an explanation of each amount listed, match the code in the Remark Code column with the corresponding one in the Remark Code Description section. Remark Code ‐ The code used regarding payment. The code is defined under Remark Code description. Type of Service ‐ The numeric code for type of service rendered. The code is defined under Type of Service rendered. Cost Management Savings ‐ You are not responsible for this amount because you received services from an In Network provider or from a provider that was willing to negotiate his or her fee. The discount was negotiated with the provider of service on your behalf. The affiliation, if shown, indicates the provider organization through which the discounts were negotiated. Deductible Amount ‐ The amount shown is the amount applied to toward the patient’s deductible. The deductible is your responsibility to pay. Deductibles are described in your Benefit Book and on your Schedule of Medical Benefits. plan. Covered Expenses ‐ The amount shown is the amount that is considered for payment by your benefit Balance ‐ The amount shown is the amount charged minus the ineligible, cost management savings, copay and deductible amount. Pay % ‐ The amount shown is the benefit percentage that was paid by your benefit plan. Amount Payable ‐ The amount shown is the benefit amount paid by your benefit plan. Out of Pocket ‐ This is the portion of the Covered Benefits that is the patient’s responsibility. Non Network amounts may not apply to the cumulative out of pocket depending on plan design. Patient’s Total Responsibility ‐ If there is no Other Payment Adjustment amount, the Patient’s Total Responsibility equals the Total Charge less Cost Management Savings less Other less Total Benefit. Note: The Patient’s Total Responsibility will not be shown if there is an Other Payment Adjustment amount or if this EOB is for an adjusted claim. Other – This is the total of any charges listed in the Ineligible column for which we are awaiting documentation or for which we have determined the provider may have inappropriately coded this service or for which we determined the amount was a duplicate. Upon receipt of the requested information, a decision will be made to determine which, if any, of these charges are eligible expenses. If the provider believes that the charges were appropriately coded and billed, supporting documentation must be submitted for further review to determine if any additional allowance is warranted. If the amount is for a duplicate, no action is necessary. If you have any questions regarding this information, please call TML Intergovernmental Employee Benefits Pool. Benefit Facts Guide (Rev 8‐30‐11) 7 | Page PRESCRIPTION SCHEDULE OF BENEFITS MEDICAL BENEFITS OUTPATIENT PRESCRIPTION DRUG BENEFIT ~ FY11‐12 MAXIMUM ALLOWABLE COST RESTAT CARD PROGRAM (MAC «PLAN») ALIGN/BROAD RETAIL NETWORK AND MAIL SERVICE BENEFIT OPTION «GRPNAME» Effective Date: «PLANDATE» This benefit schedule is made a part of the Plan for the purchase of outpatient prescription drugs. All charges for outpatient prescription drugs are covered under this benefit and are not considered eligible expenses unless purchased through this program. Generic Prescriptions Could be a Viable Savings Opportunity! With healthcare costs continuing to rise, generic medicine might be an easy and effective way to minimize out of pocket expenses. 1.
Generic medications are reviewed by the US Food and Drug Administration (FDA) for safety and efficacy and are manufactured under the strict standards that apply to brand‐name drugs and not protected by a trademark. 2.
Generic medications create competition, which assists in keeping the costs of prescriptions competitive. 3.
Research shows that plan participants may save an average of 30% to 80% when they fill their prescriptions with a generic instead of a brand‐name medication. Brand Name Drugs Drugs produced and marketed exclusively by a particular manufacturer. The drug name is usually registered as a trademark. Maximum Allowable Cost (MAC A) If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the difference between the brand name and generic price in addition to the appropriate copayment for the brand name. The cost difference between the brand name and generic price does not apply to any individual deductibles or out of pocket amounts. The MAC differential applies to all prescriptions purchased through this program when a generic alternate is available. Maximum Allowable Cost (MAC C) Covered Individual will pay the appropriate copayment amount of the prescription. Benefit Facts Guide (Rev 8‐30‐11) 8 | Page Retail Covered Individual Copayments Retail: Covered Individual OOP (34 days supply max unless noted otherwise) Mail/Maintenance 84/90 day dispensement Biotech/SpecialtyRx 34 day dispensement Covered Individual Out Of Pocket Over the Counter Alternates: Non‐Sedating Antihistamines (Claritin®, Alavert®, Allegra®, Allegra‐D®, Zyrtec®, Zyrtec‐D®) per prescription Stomach and Ulcer (Prilosec®, Prevacid®, Zegerid®) per prescription Smoking Cessation (Nicorette Gum) Quantity Limit ‐ 3 boxes per plan year $0.00 N/A Align Network Value Tiered 34 day non Cost Share generic dispensement $0.00 (up to 34 days supply) N/A Align Network Value Tiered up to 90 day non Cost Share generic dispensement $9.00 (35 to 90 days supply) N/A Broad Network non Cost Share Generic $10.00 $25.00 Broad and Align Network non Cost Share Best Price Brand List $38.00 $95.00 Broad and Align Network non Cost Share Non‐Best Price Brand List $60.00 $150.00 Broad and Align Network Cost Share – see Cost Share Copay $120.00 Drugs below $300.00 Specialty/Biotech Prescriptions $100.00 for up to 34 day supply N/A Cost Share Copay Drugs Cost Share Drugs Alternative Drugs Antibiotics: Anti‐Infective Agents Impacts utilization on: Adoxa®, Doryx®, Dynacin®, Monodox®, Periostat®, Solodyn®, Oraxyl®, Oracea® Generic Generic Minocycline® (for Dynacin®, Solodyn®) Doxycycline® (for Adoxa®, Doryx®, Monodox®, Periostat®, Oracea®, Oraxyl®) Central Nervous System: Sedative Hypnotics Impacts utilization on: Ambien®, Ambien CR®, Edluar®, Lunesta®, Rozerem®, Sonata®, Zolpidem ER® Generic Generic Zolpidem® Immediate Release (for Ambien®) Zaleplon® (for Sonata®) Stomach Ulcer/Reflux Drugs/Gastrointestinal/Stomach: Proton Pump Inhibitors Impacts utilization on: Aciphex®, Dexilant® (formerly Kapidex®), Nexium®, Lansoprazole®, Prevacid®, Prilosec®, Protonix®, Vimovo® OTC OTC OTC Generic Generic Prevacid® Prilosec® Zegerid® Omeprazole® Pantoprazole® Respiratory/Allergy/Asthma: Antihistamines Impacts utilization on: Fexofenadine®, Clarinex®, Xyzal® OTC OTC OTC Generic Generic Allegra® Zyrtec® Claritin® Loratidine® Cetirizine® Respiratory/Allergy/Asthma: Antihistamines‐Decongestant Impacts utilization on: Fexofenadine‐D®, Clarinex‐D® OTC OTC Generic Generic Generic Allegra‐D® Zyrtec‐D® Claritin‐D® Loratidine‐D® Cetirizine‐D® Benefit Facts Guide (Rev 8‐30‐11) 9 | Page Cost Share Drugs Alternative Drugs Nasal Steroids Impacts utilization on: Beconase AQ®, Flonase® (brand), Nasacort AQ®, Nasalide® (brand), Nasarel®, Nasonex®, Omnaris®, Rhinocort AQ®, Veramyst® Generic Generic Fluticasone® (for Flonase®) Flunisolide® (for Nasalide®) ADHD Impacts utilization on: Immediate Release Amphetamine Products (Adderall®, Dexedrine®, Dextrostat®) Immediate Release Methylphenidate Products (Ritalin®, Foclin®) Extended Release Amphetamine Products (Adderall XR®, Dexedrine Spansules®) Extended Release Methylphenidate Products (Concerta®, Daytrana®, Metadate CD®, Ritalin LA®) Generic Generic Brand Brand Brand Methylphenidate® Amphetamine® Strattera® Vyvanse® Focalin XR® Osteoporosis Drugs Generic Impacts utilization on: Actonel®, Actonel® w/Calcium, Atelvia®, Boniva®, Fosamax®, Fosamax‐D® Alendronate® (for Fosamax®) Migraine Headaches Impacts utilization on: Amerge®, Axert®, Frova®, Imitrex® (brand), Relpax®, Treximet®, Zomig®, Zomig ZMT® Generic Brand Sumatriptan® (for Imitrex®) Maxalt® Overactive Bladder Drugs Impacts utilization on: Detrol®, Detrol LA®, Ditropan® (brand), Ditropan XL®, Gelnique®, Enablex®, Oxytrol® Patches, Sanctura®, Toviaz®, Vesicare® Generic Oxybutynin® Immediate Release (for Ditropan®) Medication Therapy Management Program At the time of this printing, the Value Tiered/Align Network Pharmacy Extension includes the following pharmacies: •
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Boomtown Drug Brookshire Brothers Chapel Hill Pharmacy City Market Pharmacy Cody Drug Cody Pharmacy Collingsworth Pharmacy Cub Pharmacy Davis City Pharmacy Diamond Pharmacy Dillon Stores Doc's Drugstore of Brownwood Doc's Drugstore of Early Dominick’s Eagle Lake Pharmacy Farm Fresh Fikes Pharmacy Fred Meyer Fry’s Food & Drug Graham Pharmacy Benefit Facts Guide (Rev 8‐30‐11) •
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HealthMart Pharmacy (Access Health) HEB Hico Pharmacy Holmes Pharmacy Hughes Pharmacy Kenjura Pharmacy King Soopers Kings Daughters Pharmacy Kmart Kroger Luna's Friendly Pharmacy Maloney Pharmacy Med Shop Pharmacy Medical Arts Drug (Waldie's Pharmacy) Medicine Chest Medicine Shoppe of Henderson Overton Pharmacy Plaza Pharmacy Quality Food Centers Ralph’s •
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Randall’s Safeway Sam’s Club Sav‐On Pharmacy Shopko Smiths Star Markets Super Mercado's Pharmacy Target The Friendly Pharmacy The Medicine Shoppe of Jasper Tom Thumb Troup Pharmacy United Care Pharmacy Vista Pharmacy Vons Companies Inc. Waldie's Pharmacy Walmart Walter's Pharmacy Whitehouse Pharmacy 10 | Page Clinical Prior Authorization The list of conditions below may change as appropriate for the plan. For prior authorization requests, please have your doctor/prescription prescriber call RxResults at (888) 871‐4002. Your doctor/prescription prescriber will be asked a series of questions and RxResults will then approve or deny the authorization request. ANTIBIOTICS 9 ZYVOX® ASTHMA INHALERS ASTHMA NON INHALERS Requests may be granted to patients who have demonstrated compliance to an inhaled steroid and/or satisfied additional clinical criteria as determined by the prior authorization review. Treatment Plan Adherence is required for authorization to be approved. 9 ADVAIR® 9 BROVANA® 9 DULERA® 9 FORADIL® 9 PERFOROMIST® 9 SEREVENT® 9 SYMBICORT® GENERAL 9
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XOLAIR® Injection ACCOLATE® SINGULAIR®* ZYFLO® Covered only for asthma as a second‐line drug, after an inhaled steroid. Use is excluded for allergies and/or allergic rhinitis. Requests may be granted to patients who have demonstrated compliance to an inhaled steroid and/or satisfied additional clinical criteria as determined by the prior authorization review. Treatment Plan Adherence is required for authorization to be approved. 9 Attention Deficit Disorder ADHD (For individuals 17 years of age or older) These medications may be reimbursed following satisfaction of clinical criteria as determined by prior authorization review. 9 Narcolepsy Medications (For individuals 17 years of age or older) 9 Acne Medications (For individuals 26 years of age and older) MAJOR BIOTECH PRESCRIPTION CATEGORIES TESTOSTERONE ALL PRODUCTS DIABETES OSTEOPOROSIS 9
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Blood Cell Deficiency Crohn’s Disease Cystic Fibrosis Growth Hormones Hemophilia Hepatitis C HIV/Immune Deficiency Medications Multiple Sclerosis Oncology Oral Osteoarthritis Psoriasis Pulmonary Arterial Hypertension Renal Disease Rheumatoid Arthritis All Others 9 ANDROGEL® (covered only for hormone replacement not for erectile dysfunction) 9 ANDRODERM® 9 TESTIM® Actual lab results defining the testosterone level will be required. The lab report will indicate whether the level is low or within normal ranges. 9 JANUVIA®/JANUMET® (covered for diabetes only) 9 SYMLIN® 9 BYETTA® 9 VICTOZA® 9 ONGLYZA® 9 KOMBIGLYZE® 9 TRAJENTA® These medications may be reimbursed following satisfaction of clinical criteria as determined by prior authorization review. 9 FORTEO® Note: All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without notice to accommodate new drug entries to the marketplace and adjustments in established medical and pharmacy practice guidelines. Benefit Facts Guide (Rev 8‐30‐11) 11 | Page Step Therapy •
For Clinical Authorization, doctor/prescription prescribers should call RxResults at (888) 871‐4002. Your doctor/prescription prescriber will be asked a series of questions and RxResults will then approve or deny the authorization request. •
Sample of what will occur at pharmacy Claim is processing for Advair® & the following message will alert the pharmacist: Step Therapy after inhaled steroid 1st or Prior Authorization call (888) 871‐4002. TML IEBP Step Therapy Drug Categories ASTHMA HIGH BLOOD PRESSURE (ANGIOTENSIN RECEPTOR BLOCKERS/ARB’S) Required for members <40 years of age who have not If the member fills a medication in Category B, they will NOT need to demonstrated adherence to an inhaled corticosteroid (ICS) start with Category A, unless they haven’t used the medication for 100 (90 days of therapy in the past 120 days). days. If the member is beginning therapy (regardless of age), only an inhaled steroid will be approved unless otherwise approved by RxResults. Category A Category A 9 Inhaled Corticosteroid (ICS) ‐ Member must 9 Any generic ACE inhibitor or ACE‐combination demonstrate adherence to an inhaled steroid and/or 9 Losartan®/Losartan HCTZ® satisfy specific clinical criteria as determined by RxResults prior to obtaining a Category B medication. Category B (Only after failure with a Category A medication) 9 ADVAIR® 9 BROVANA® 9 DULERA® 9 FORADIL® 9 PERFOROMIST® 9 SEREVENT® 9 SYMBICORT® Category B (Only after failure with a Category A medication) The doctor/prescription prescribers must provide documentation from the Covered Individual’s medical record indicating that prior treatment with an ACE inhibitor resulted in a cough or angioedema. 9 ATACAND®/ATACAND HCT® 9 AVAPRO®/AVALIDE® 9 BENICAR®/BENICAR HCT® 9 COZAAR®/HYZAAR® (Brand only) 9 DIOVAN®/DIOVAN HCT® Treatment Plan Adherence is required for authorization to 9 EDARBI® be approved. 9 EXFORGE®/EXFORGE HCT® 9 MICARDIS®/MICARDIS HCT® 9 TEKTURNA®/TEKTURNA HCT® 9 TEKAMLO® 9 TEVETEN®/TEVETEN HCT® 9 TRIBENZOR® 9 TWYNSTA® 9 VALTURNA® 9 AZOR® Note: All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without notice to accommodate new drug entries to the marketplace and adjustments in established medical and pharmacy practice guidelines. Important Information ƒ
TML IEBP Billing & Eligibility: (800) 282‐5385 ƒ
RxResults (Doctor/Prescription Prescribers Only): (888) 871‐4002 ƒ
TML IEBP Website: http://www.tmliebp.org Benefit Facts Guide (Rev 8‐30‐11) 12 | Page Drugs Covered Under This Benefit 1.
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Legend Drugs; Insulin or oral diabetic prescription; Disposable insulin needles/syringes and physician prescribed needles/syringes; Disposable blood/urine/glucose/acetone testing agents (e.g. Acetest Tablets, Clinitest Tablets, Glucometer (one per calendar year), Lancets, Diastix Strips, Tes‐Tape and Chemstrips; Diabetic supplies will be purchased with order for oral diabetic prescription. The plan will allow needles, syringes, lancets and testing strips at no charge if ordered within 30 days of a prescription at the same pharmacy; Tretinoin all dosage forms (e.g. Retin‐A, Differin, Tazorac) for Individuals through the age of 25 years; Compound medication of which at least one ingredient is a legend drug; Any other drug which under the applicable State Law may only be dispensed upon the written prescription of a physician or other lawful prescriber; Contraceptives: Oral, Extended cycle (mail order only), Transdermal patches, Contraceptive devices, Levonorgestrel (Norplant), Prescription Strength Only; Depo Provera; Central Nervous System Stimulants (e.g. Adderall, Adderall XR, Focalin, Focalin XR, Ritalin, Dexedrine, etc) will be covered for individuals through age 16. (Individuals 17 years and older will require prior authorization through RxResults.); Prescribed smoking deterrent medications containing nicotine or any other smoking cessation aids, all dosage forms; Growth hormones through age 15; Extended Release anti‐depressive agents: Wellbutrin XL, Effexor XR; Extended Release migraine prophylactic agents: Depakote ER; Single entity legend vitamins. Drugs Not Covered Under This Benefit 1.
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Dietary supplements, vitamins or formulas; Growth hormones after age 15; Immunization agents, biological sera blood or blood plasma; Male pattern baldness medications; hair growth stimulants; Tretinoin, all dosage forms (e.g. Retin‐A, Differin, Tazorac) for individuals 26 years of age or older; cosmetic agents including anti‐wrinkle, Botox and skin depigmenting agents; Vitamins individually or in combination; Therapeutic devices or appliances, including support garments and other non‐medicinal substances, regardless of intended use; Charges for the administration or injection of any drug; Drugs labeled “Caution ‐ limited by Federal Law to investigational use” or experimental drugs even though a charge is made to the individual; Medications which are to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar premises which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals; Emergency contraceptives; Fertility medications; Any prescription refilled in excess of the number specified by the physician or any refill dispensed after one year from the physician’s original order; Prescription which an eligible individual is entitled to receive without charges from any Workers’ Compensation Laws or which is prescribed for an injury or illness which is excluded from any medical coverage which is provided in conjunction with this prescription benefit; Anti‐obesity medications; Prescribed prenatal vitamins are not covered under the Restat card. Claims for prescribed prenatal vitamins with a pregnancy diagnosis may be submitted to TML IEBP for payment consideration; Non‐legend drugs other than those listed above; Lifestyle convenience prescriptions (ie: erectile dysfunction prescriptions). Benefit Facts Guide (Rev 8‐30‐11) 13 | Page SpecialtyRx/Biotech Prescriptions TML IEBP offers a Pharmacy Benefit Manager SpecialtyRx service. This service provides a convenient and cost‐effective way to order injectable drugs and supplies through Pharmacy Benefit Manager SpecialtyRx. The Specialty/Biotech copay for a 34 day Specialty Prescription is $100.00. To see a list of Specialty/Biotech drugs available through the Pharmacy Benefit Manager, please log in to the myTML IEBP web portal and click the “Prescription Benefits” link. SpecialtyRx is the most cost‐effective way to purchase medications for Covered Individuals with chronic illnesses requiring life‐sustaining medications. SpecialtyRx provides Covered Individuals with a cost‐effective benefit to purchase specialty prescriptions. With SpecialtyRx, the Covered Individual will receive easy ordering and fast delivery from the Specialty Pharmacy. In addition, the Covered Individual will receive an informative care management packet. The SpecialtyRx prescription may be delivered to the physician's or Covered Individual's address. The SpecialtyRx plan provides many benefits to Covered Individuals: •
Single reliable source for injectable specialty prescriptions •
For Prior Authorization Doctor/Prescription Prescribers Call RxResults (888) 871‐4002 •
Easy ordering with a toll‐free number (877) 408‐9742; 7:30am – 7:00pm CST M‐F •
Express delivery to location of your choice ~ either to the Covered Individual’s home or provider’s office (Some providers have expressed a strong opinion for the prescription to be delivered to their offices if they are required to administer the prescription.) Mail Service Prescription Option Spend Less on Your Prescriptions! TML Intergovernmental Employee Benefits Pool wants to remind you and your covered dependents about an important part of your benefit plan — the CVS/Caremark Mail Service Program. Take advantage of the Caremark Mail Service prescription benefit and you may save time and money on the medications you take each month. Getting your prescription from the mail service pharmacy is simple with FastStart. Easy as 1‐2‐3! 1.
Call FastStart toll free: Members ‐ (800) 875‐0867 Hearing Impaired ‐ (800) 231‐4403 Doctors ‐ (800) 378‐5697 2.
Call for Refill Mail Service: Members ‐ (888) 739‐7989 3.
Let the FastStart representative know you wish to fill your prescription order through mail service. 4.
Provide the information on your benefit ID card, the names of the long‐term medications you take, your doctor’s name and phone number, and your mailing address. Medication Refills •
Retail refills will be approved upon 75% of utilization. •
Mail Service refills will be approved upon 60% of utilization. Emergencies On occasion, you may need to get a prescription filled immediately. Ask your physician to write two prescriptions, one for a 21‐day supply of medication to be filled locally and the second for the balance (up to 90 days). The 21‐day supply prescription filled locally will be covered according to the prescription drug benefit included in your Plan. Order forms are included in your employee packets and are available from the TML Intergovernmental Employee Benefits Pool or your employer. A re‐order form will accompany each order you receive. Benefit Facts Guide (Rev 8‐30‐11) 14 | Page Identification Cards Each Covered Individual will be issued an ID card. You must present your ID card to the pharmacist at the time of purchase. If a Covered Individual does not have the ID card at the time of purchase these steps must be followed: 1.
Pay for the entire cost of the prescription. 2.
Obtain and complete a direct prescription drug Restat claim form. These are available from your employer or TML Intergovernmental Employee Benefits Pool. 3.
Send the Restat drug claim form with the prescription receipt directly to Restat. Restat will pay the appropriate amount, less the copayment and Maximum Allowable Cost (MAC) differential (if applicable), directly to the Covered employee usually within 30 days. Benefit Facts Guide (Rev 8‐30‐11) 15 | Page RESTAT MEMBERREPORTAL: FREQUENTLY ASKED QUESTIONS Restat is pleased to provide you with a member website designed to help you monitor and manage your prescription plan benefits. MemberREPortal will allow you to: •
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Review your claim history Research drug pricing Check for best brand price information or generic equivalents Check for drug interactions Locate Restat Provider Network Pharmacies How do I access MemberREPortal? Access www.tmliebp.org, and log into my TMLIEBP. Once login is complete, go to the Additional Benefits dropdown and select Prescription Benefits. This will take you to the login page. To access your prescription benefits and history, select the Register Now link and complete the registration page. To complete the registration page, you will need to have an email address and your benefit card which includes your Unique ID Number (not your SSN#) and Restat Customer Number. (If you do not have a valid email address, select the Click Here link located on the login page to create a free Yahoo! email account.) You must type the information exactly how the prescription benefit information appears on your ID Card. ID #: Enter your Unique ID in the ID# field FIRST NAME: type it exactly as it appears on the prescription side of your ID card (include the middle initial if it appears) LAST NAME: type it exactly as it appears on the prescription side of your ID card (include the suffix if it appears) CUSTOMER #: Enter Customer # in Customer#/Plan#/Group# field exactly as it appears on the prescription side of your ID card After successful completion of the registration process, you will automatically return to the login page where you can login to MemberREPortal. An email confirmation of your registration will be sent to your email address entered during the registration process. After initial registration and signon, you log into myTML IEBP at www.tmliebp.org and will be automatically be signed into MemberREPortal. Can I access information for all of my family members? Due to HIPAA (Health Insurance Portability and Accountability Act) requirements and compliance, some restrictions apply to the availability you will have to your family’s prescription data. The covered individual will have the ability to view data on his/herself and any children. In order to preserve the right to privacy, the cardholder will not be allowed to view the information for their spouse and adult children. The cardholder’s spouse and adult children must create their own account on MemberREPortal to view data only for themselves. They will not have access to data for any other family member. Benefit Facts Guide (Rev 8‐30‐11) 16 | Page Who do I contact if I am having problems using MemberREPortal? If you encounter any issues while using MemberREPortal simply select the Contact Us link provided on our website. This will allow you to send an email to Restat’s Help Desk for assistance. What happens if I forget my User Id or password? If you forget your User Id or password, go to the login screen and select the Password Help link. This action will prompt you for the answer to the hint question that you provided during the registration process. Entering the correct response to the hint question will automatically send you an email with your password. How do I change my password? To change your password, select the Your Account Profile link located at the bottom of any screen. On the Account Profile screen you can change your password and hint question/answer at any time, or update your personal data. What type of information does MemberREPortal offer? MemberREPortal allows you to manage and monitor your prescription benefits through the links listed on the left hand side of the screen as displayed below. Information presented is specific to the benefits of your prescription benefits plan. •
Drug Pricing Lookup — By entering the name of a drug or a medical condition you can research the cost of the drug and copay amount you can expect to pay. •
Best Brand Price—The Preferred Product link will allow you to generate a report that lists the best brand products that your plan has indicated as best brand price based on cost savings and/or performance. (Best Brand = Preferred Product) •
Benefit Report ‐ Provides a summarized report of your prescription claims. To run the report, enter the starting and ending month and year to be used for the selection of claims. •
Your Claim History ‐ Provides a report detailing information on your prescription benefit claims. This report will produce a detailed list of all prescriptions submitted between the starting and ending period that you enter. •
Drug Interactions —Allows you to check a drug interaction and will list your drugs that have been filled during the last 90 days. You can then add additional medications until you have a complete list of all your medications. •
Drug Uses — Allows you to enter a medication and provides a report with a description of the drug and the conditions the drug is designed to treat, how to store or handle the medication and any potential side effects. Pharmacy Locator— The pharmacy locator allows you to find a pharmacy that participates in your prescription benefit plan by providing your zip code or address (To locate a pharmacy with Value tiered copays—select the drug pricing lookup option, and provide your zip code to find pharmacies offering the lower Value tier copay.) •
Benefit Facts Guide (Rev 8‐30‐11) 17 | Page MEDICAL CARE MANAGEMENT FEATURES This program is included to assist you in making informed healthcare decisions. Occasionally, proposed healthcare or the scheduled length of stay or setting is not an Eligible Benefit. Please read this provision so that you understand the admission, continued stay and notification process and are not faced with an out of pocket cost, penalty or denial for failure to provide Notification. Even when Notification is provided, reimbursement is subject to the terms and conditions of the Plan including, but not limited to, all plan exclusions and limitations. Providing the required Notification does not constitute verification of eligibility of benefits. Notification is required for Integration of Benefits when this Plan is secondary to other coverage. If Medical Care Management does not receive Notification prior to a scheduled service requiring Notification, claims for benefits for that service will not be considered unless an appeal is filed and reviewed. If the medical services are eligible under the Plan, they will be paid, but the Late Notification Penalty will apply. How The Notification Process Works The Twenty‐Three (23) Hour Rule For the purpose of notification, inpatient means treatment or confinement in a hospital or other medical facility for more than twenty‐
three (23) hours. Outpatient means treatment or confinement in a hospital or other medical facility for twenty‐three (23) hours or less. What is an admission? When the hospital or facility submits a claim, the length of time the covered individual was in their facility and a designation of inpatient, outpatient or observation is included. The number of hours, not the classification, determines if the stay is twenty‐three (23) hours observation or inpatient. If it appears that the Covered Individual will stay more than twenty‐three (23) hours, Notification of the stay must be provided to Medical Care Management. Medical Care Management must be called for any inpatient expectant mother admission. If a newborn requires more than routine nursery care, Medical Care Management must be provided Notification so that a separate determination can be issued for the baby. Newborns must be added to the Plan within sixty (60) days of birth in order to be a covered individual. Responsibilities of the Covered Individual Between the hours of 8:30 AM ‐ 5:00 PM Central time, call the Medical Care Management number on the Medical/Prescription ID card to provide Notification to Medical Care Management prior to any healthcare service that requires notification. After hours, Voice Mail records your notification twenty‐four (24) hours‐a‐day and the Medical Care Management department will return your call the next business day. Notification Requirements Notification enables clinical support and educations, such as: •
Perform pre‐op education for the patient and ensure adherence to nationally recognized guidelines in order to maximize quality and cost efficiency •
Facilitate post‐op discharge planning to optimize clinical outcomes •
Refer patients to Centers of Excellence Notification is required for the following admissions and/or procedures: SERVICE • INPATIENT ADMISSIONS NOTIFICATION LATE NOTIFICATION PENALTY Scheduled Specialty Admissions • Orthopedic/Spine Surgeries (spinal surgeries, total knee replacements, and total hip replacements) • Transplants: At least ten (10) working days prior to any pre‐
transplant evaluation, the covered individual or a family member must provide Notification to Medical Care Management; failure to do so will result in a Late Notification Penalty of $400 or a reduction in benefits • Reconstructive/Potentially Cosmetic procedures • Bariatric Surgeries: Morbid Obesity Services (after the approved six (6) month physician supervised weight management Facility: twenty‐four (24) hours after actual admission or by 5 pm the next business day for weekend/holiday admissions Facility: If admission Notification is not received within seventy‐two (72) hours of the admission, a 50% reduction will be applied to the contracted benefit eligible rate. Benefit Facts Guide (Rev 8‐30‐11) Primary Physician/Healthcare Professional: Prior to Admission Primary Physician/Healthcare Professional: If an advanced admission Notification is not received, a 100% reduction will be applied to the contracted benefit eligible rate. 18 | Page SERVICE treatment plan) • Congenital Heart Disease Other Inpatient Admissions • Skilled Nursing Facility • Psychiatric/Chemical Dependency Inpatient • Psychiatric/Chemical Dependency Residential Treatment • Acute Care Hospital/Facility • Long Term Acute Care Facility • Acute Rehabilitation Facility • Scheduled Cesarean Section Delivery NOTIFICATION LATE NOTIFICATION PENALTY Facility: twenty‐four (24) hours after actual admission or by 5 pm the next business day for weekend/holiday admissions Facility: If admission Notification is not received within seventy‐two (72) hours of the admission, a 50% reduction will be applied to the contracted benefit eligible rate. Inpatient Pregnancy/Maternity (Delivery Admission) • Vaginal Delivery admission in excess of forty‐eight (48) hours • Cesarean delivery admission in excess of ninety‐six (96) hours • All High Risk obstetrical or antepartum care or other undelivered admission • Newborns who remain in the hospital after mother is discharged Pregnancy/Maternity • Sonogram/Ultrasound in excess of three (3) • Amniocentesis • Home Health (uterine monitoring) • Multiple birth diagnosis Facility: twenty‐four (24) hours after actual admission or by 5 pm the next business day for weekend/holiday admissions Facility: If admission Notification is not received within seventy‐two (72) hours of the admission, a 50% reduction will be applied to the contracted benefit eligible rate. Prior to commencement for outpatient and Home Health procedures, within forty‐eight (48) hours of multiple birth diagnosis $200 Three (3) working days prior to procedure $200 Prior to commencement $200 Prior to commencement $200 •
SCHEDULED OUTPATIENT/OFFICE SURGICAL PROCEDURES •
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Blepharoplasty (eyelid surgery) Breast Surgery Carpal Tunnel Release (nerve decompression) Jaw Surgery (including mandibular joint) Joint Surgery (excluding fingers & toes) Laparoscopy (except sterilization) Myringotomy or Myringoplasty (tympanic/ear drum surgery) Nasal Surgery Tonsillectomy and/or Adenoidectomy Uvulopalatoplasty (roof of mouth surgery) Reconstructive Surgery Cochlear Device and/or implantation Artificial Intervertebral Disc Surgery Stereotactic Radiosurgery Bariatric Surgery (obesity surgery) •
OUTPATIENT/OFFICE INFUSION THERAPY •
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For Pain Management Chemotherapy •
MISCELLANEOUS •
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Psychiatric/Chemical Dependency Day Treatment Hospice Home Health Care Physician Home Visit Cardiac Rehabilitation Pulmonary Rehabilitation Positron Emission Tomography (PET) scans Computerized Axial Tomography (CAT) scans Computerized Tomographic Angiography (CTA) scans Magnetic Resonance Imaging (MRI) scans Magnetic Resonance Angiography (MRA) scans Single Photon Emission Computed Tomography (SPECT) Benefit Facts Guide (Rev 8‐30‐11) 19 | Page SERVICE • Dental Injury (inpatient and outpatient) • Dialysis for Kidney/Renal Failure • Hyperbaric Oxygen Therapy • Radiation Therapy • Medically Necessary Evidence Based Genetic Testing NOTIFICATION LATE NOTIFICATION PENALTY •
For charges in excess of $1,000 prior to purchase, lease or rental $200 Durable Medical Equipment Responsibilities of Medical Care Management Medical Care Management does not confirm eligibility or benefits for any treatment or service. Upon Notification, Medical Care Management will provide the Covered Individual or Provider with contact information to enable the person to confirm eligibility and benefits with a Customer Service Representative. What Happens on Treatment in Excess of Twenty‐Three (23) Hours? The covered individual must provide Notification to Medical Care Management of a scheduled admission per Notification Requirements. If the Notification is made after the above‐referenced time frames, a Late Notification Penalty or reduction of benefits will apply. Concurrent stay review requirements apply to all inpatient confinements. Failure to provide Notification to Medical Care Management will result in no paid benefits for facility or related charges. What Happens if Outpatient Services Go Over the Twenty‐Three (23) Hour Limit? Outpatient Surgery not on the Outpatient Surgery List If Notification is provided to Medical Care Management within Notification Requirements of an outpatient surgery that exceeds the twenty‐three (23) hour limit, it will be considered an admission, and a late review will be performed. If the services and the length of stay are Eligible Benefits, there is no penalty. If the services are determined to be non‐Eligible Benefits, charges are not covered. If you do not provide Notification to Medical Care Management within the Notification Requirement of the admission, the outpatient Late Notification Penalty will apply. Failure to provide Notification to Medical Care Management will result in no paid benefits for related charges. Outpatient Surgery on the Outpatient Surgery List If Notification was provided on a scheduled surgery requiring Notification and unforeseen circumstances require more than a twenty‐
three (23) hour stay, the continued stay review process is required. If the length of continued stay is determined to be inappropriate, charges related to the time for which Notification was not provided will not be a paid benefit. A Late Notification Penalty will not be applied if prior Notification was provided and the services and length of stay are determined to be appropriate. Emergent or Immediate Care (Unscheduled) Medical Admission If Notification is provided to Medical Care Management within Notification Requirements for emergent or immediate care, no Late Notification Penalty will apply. Maternity Care Maternity care means services rendered to treat and maintain a pregnancy that is covered under this plan. Maternity care includes prenatal visits and testing, delivery of the child, post‐partum care, and routine care of the newborn child while the mother is Hospital confined. Notification is required to Medical Care Management within forty‐eight (48) hours of multiple birth diagnosis. Continued Stay Review If the covered individual’s treatment plan changes, the Healthcare Provider must provide Notification to Medical Care Management at (800) 847‐1213. Medical Care Management will obtain an update on the treatment plan and will conduct a concurrent review regarding the additional length of stay. Medical Intensive Care Management Medical Intensive Care Management services help you use your benefits wisely during periods of treatment due to serious sickness or injury. This is done through early identification of the need for Medical Intensive Care Management, followed by on‐going work with you and your provider to plan health care alternatives to meet your needs. The Medical Intensive Care Manager will try to conserve your benefits by making sure that your care is handled as efficiently as possible. The Medical Intensive Care Management staff consists of licensed, professional nurses. The nurses have years of experience in health care and know the importance of not intruding in the doctor/patient relationship. By promoting health care alternatives that are acceptable to Benefit Facts Guide (Rev 8‐30‐11) 20 | Page you, your doctors and your employer, Medical Intensive Care Management helps to control health care costs and use your benefits wisely. Medical Intensive Care Management is an option. However, should Medical Intensive Care Management be refused by the covered individual or physician, benefits will pay at the Non Network benefit percentage and will not, at any time, pay at 100% for any medical services under the out of pocket provision of the Plan. If Medical Intensive Care Management is refused, all future payments for any medical services will be paid at the reduced benefit. The individual deductible and out of pocket amount must be met each calendar year. Population Health Engagement Population Health Engagement supports members in all stages of health. This program provides information to the covered individual regarding healthy lifestyle choices and management of chronic disease states. The program offers personalized professional coaching to support the healthy lifestyle of change and plan of action. Online tools and educational material(s) are available to the covered individual. The population health engagement team consists of an interdisciplinary team of licensed professional nurses, counselors, behaviorists, registered dietitians and certified diabetes educators. Self‐Audit Reimbursement (Refer to your Schedule of Medical Benefits.) Any covered individual who reviews eligible medical benefits and discovers an overcharge made by the medical facility or practitioner may provide the Group Benefits Administrator with a copy of the original billing, corrected billing and an explanation. The covered individual will be reimbursed 30% of the amount of savings generated. The reimbursement may not exceed the covered individual's individual calendar year deductible and out of pocket amount. Benefit Facts Guide (Rev 8‐30‐11) 21 | Page TAKE CHARGE OF YOUR HEALTH •
Maintain a Personal Health Record ‐ A Personal Health Record (PHR) is a handy way to record and recall your medical history, past procedures, diagnoses, medications, allergies, biometric screenings, etc. Engage in physician approved regular exercise Manage your stress Keep up with preventive screenings Stop Smoking Drink alcohol in moderation Improve Diet Lose Weight Practice Good Hygiene •
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INTERNAL AND EXTERNAL APPEAL OPTIONS Appeals TML IEBP will conduct a full and fair review of your appeal. The appeal will be reviewed by appropriate individual(s) on the TML IEBP staff for internal review; or a health care professional with appropriate expertise during the initial benefit determination process. The appellant may request an independent review from an independent state licensed external review organization that is credentialed under URAC (Utilization Review Accreditation Commission). The external review will be conducted by a random URAC selected reviewer who was not consulted initially during the external clinical excellence review. Once the review is complete, if the denial is maintained, the appellant will receive a written explanation of the reasons and facts relating to the denial. Appeal of Emergent Care Request for Benefits (Adverse Notification Determination Prior to Claim Submission) Appeal of Urgent/Emergent Request for Benefits
(Adverse Pre‐Determination/Notification Request) Type of Request for Benefits or Appeal Internal/External Process Business Hours/Days If the appellant appeals the adverse notification determination or Internal declination of notification, the appellant must appeal within: one hundred eighty (180) days after receiving the denial based on a completed review process If the appellant’s request for emergent benefits is incomplete TML Internal IEBP will send the urgent/emergent incomplete pre‐
determination/notification information declination letter within: twenty‐four (24) hours of receipt of appellant’s information The appellant must provide a completed information request Internal within: forty‐eight (48) hours after receiving the TML IEBP declination due to incomplete information If the request for urgent/emergent benefits is complete and not Internal approved, TML IEBP will send an urgent/emergent pre‐
determination/notification denial letter within: seventy‐two (72) hours If the appellant’s request an Independent Review Organization, External (IRO), the external review appeal request must be submitted for the review within: one hundred twenty (120) days of receipt of the original denial or response to your appeal Benefit Facts Guide (Rev 8‐30‐11) 22 | Page Appeal of Urgent/Emergent Request for Benefits
(Adverse Pre‐Determination/Notification Request) Type of Request for Benefits or Appeal Internal/External Process The IRO will complete the review and TML IEBP will submit the External response of an expedited urgent/emergent pre‐
determination/notification of a benefit appeal within: Business Hours/Days seventy‐two (72) hours Appeal of Non Emergent Care Request for Benefits for Pre Determination/Notification Prior to Claim Submission Type of Request for Benefits or Appeal The appellant must appeal the denial no later than: Appeal of Non‐Emergent Request for Benefits
(Adverse Pre‐Determination/Notification Request) Internal/External Business Hours/Days Appeal Process Internal one hundred eighty (180) days after receiving the denial If the request for a pre‐ determination/notification is benefit Internal information incomplete, TML IEBP will notify the appellant within: five (5) days If the request for pre‐determination/notification is clinical Internal information incomplete, TML IEBP will notify you within: fifteen (15) days The appellant must then provide completed information within: Internal forty‐five (45) days after receiving an extension notice* TML IEBP will notify you of the first level appeal decision within: Internal fifteen (15) days after receiving the first level appeal The appellant must appeal the first level appeal (file a second level Internal appeal) within: sixty (60) days after receiving the first level appeal decision TML IEBP will notify you of the second level appeal decision Internal within: fifteen (15) days after receiving the second level appeal* The appellant may request the appeal be submitted to an External Independent Review Organization, (IRO). The External Review Request must be submitted within: one hundred twenty (120) days of receipt of the original denial or response to your appeal The IRO must complete the review of a non emergent claim or External benefit appeal within: forty‐five (45) days * A one‐time extension of no more than 15 days only if more time is needed due to circumstances beyond their control Post Service Claims Appeal Type of Claim or Appeal Post‐Service Claims
Internal/External Business Hours/Days Process The appellant must appeal the claim denial no later than: Internal one hundred eighty (180) days after receiving the denial If the appellant’s claim is incomplete, TML IEBP will notify the Internal appellant within: thirty (30) days The appellant must then provide completed claim information Internal within: forty‐five (45) days after receiving an extension notice Benefit Facts Guide (Rev 8‐30‐11) 23 | Page Type of Claim or Appeal Post‐Service Claims
Internal/External Business Hours/Days Process TML IEBP will notify the appellant of the first level appeal decision Internal within: thirty (30) days after receiving the first level appeal The appellant must file the second level appeal within: Internal sixty (60) days after receiving the first level appeal decision The appellant will be notified of the second level appeal decision Internal generally within: thirty (30) days after receiving the second level appeal The appellant may request an appeal be submitted to an External Independent Review Organization, (IRO). This request must be submitted for the review within: one hundred twenty (120) days of receipt of the original denial or response to your appeal The IRO must complete the review of a non emergent claim or External benefit appeal within: forty‐five (45) days The IRO must complete a requested expedited review of an External emergent claim or benefit appeal within: seventy‐two (72) hours *Covered Individuals have access to all documents and records used in making the decision—medical consultants used in making the decision must be disclosed. If a claim for benefits is wholly or partially denied, an Explanation of Benefits (EOB) will be furnished to the covered individual and the provider of services. This EOB will give the reason(s) the claim was denied. If the covered individual or provider of services does not agree with the claim decision or alleges that a contractual prompt payment requirement was not followed in the administration of a claim, he or she may submit an appeal. Relevant information supplied by the covered individual or healthcare provider should be included with the appeal. For claims denied or partially denied for not being notified, the appeal must include: •
the admission history and physical; •
the discharge summary; and •
the operative and pathology reports (if applicable). An appeal requested without proper documentation may not be considered. All written appeals should be sent to the Plan Administrator’s address printed on the Medical/Prescription ID cards or complete the appeal form online at www.tmliebp.org. These appeal provisions shall be applicable where a provider makes a complaint that a prompt payment contract was not followed. The appealing party will be notified in writing of the results of an appeal for failure to provide Notification, and/or a denial or reduction in benefits after receipt of all necessary information to make a determination. All available medical information must be provided at no cost to the Plan. The Plan Administrator shall be under no obligation to respond to an appeal of a claim based upon complaints that have previously been addressed by a prior appeal. If the appealing party does not agree with the results of any appeal, the appeal may be elevated to the Plan’s Board of Trustees. To appeal a decision to the Board of Trustees, the appealing party must send their appeal in writing to: TML IEBP Board of Trustees, 1821 Rutherford Lane, Suite 300, Austin, TX 78754‐5151. Unless the appeal specifically requests that is a Board Appeal, TML IEBP shall have the discretion to consider the appeal on an internal staff basis. A committee of Trustees will schedule a meeting and hear the appeal. The appealing party may submit additional information and/or appear before the committee. The appealing party will be notified of the date, time and place the committee will meet at least five (5) days prior to the meeting date. A final decision will be made by the Board of Trustees Appeals Committee and sent to the appealing party. The Appeals Committee's final decision will be in writing and include specific references to the Plan provisions on which the decision was based. Benefit Facts Guide (Rev 8‐30‐11) 24 | Page PRE‐EXISTING CONDITION LIMITATIONS This pre‐existing condition limitation applies to newly hired employees and their dependents, all Late Entrants nineteen (19) years of age or older except as noted under the exception to the pre‐existing condition limitations. A pre‐existing condition is a disability for which the covered individual has: 1.
been under the care of a Healthcare Provider; or 2.
taken prescription drugs or is under the Healthcare Provider's orders to take prescription drugs; or 3.
received medical care or services (including diagnostic and/or consultative care) within the six (6) month period immediately preceding the enrollment date of benefit coverage. The benefit for all pre‐existing conditions combined for the first year of coverage is $2,000 maximum paid. Charges incurred after the first year of the covered individual’s effective date are no longer limited and Eligible Benefits for pre‐existing conditions will be paid as if the condition were any other illness. Upon the covered individual and providers completion of the pre‐existing inquiry form, the plan administrator will identify the pre‐
existing conditions that will receive the pre‐existing limited benefit. The covered individual will be notified in writing once pre‐existing information is identified. Exception to the Pre‐existing Condition Limitations 1.
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Pre‐Existing condition limitations do not apply to covered individuals who are under nineteen (19) years of age. Pre‐Existing condition limitations do not apply to charges incurred for the treatment of pregnancy. A no loss/no gain policy will apply for covered individuals enrolling at the time of the Employer Member’s initial enrollment. Any Pre‐Existing condition limitation period is reduced by the period of other “Creditable Coverage”. Creditable Coverage, as defined under the Health Insurance Portability and Accountability Act of 1996, includes coverage under most individual and group health insurance plans (including Medicare, Medicaid, governmental, State Children’s Health Insurance Program (SCHIP), Continuation of Coverage through high‐risk pools, Peace Corps and Church Plans). Creditable Coverage does not include liability, dental, vision, specified disease and/or other supplemental‐type benefits. Breaks in coverage of less than 63 consecutive days are ignored. Waiting Periods and HMO affiliation periods are not considered a break in coverage. The covered individual’s enrollment date is the first day of coverage under the plan, or, if there is a waiting period, the first day of the employer waiting period. The plan’s pre‐existing condition exclusion will be reduced by the amount of the covered individual’s prior creditable coverage. If the pre‐
existing limitation of the prior plan was not satisfied, the remaining balance of time is subject to the pre‐existing limitation of this Plan. However, if at any time the covered individual went for sixty‐three (63) days or more without coverage (called a break in coverage) the plan will not recognize the creditable coverage benefit. This Plan utilizes the standard method of determining Creditable Coverage. Benefit Facts Guide (Rev 8‐30‐11) 25 | Page GENERAL EXCLUSIONS OR LIMITATIONS No benefits shall be payable under any part of this Plan with respect to any charges: 1.
for which a covered individual is not financially responsible or are submitted only because medical coverage exists or for discounts for which the covered individual is not responsible, including but not limited to independent and preferred provider discounts; 2.
for services not eligible for diagnosis or treatment of an illness or injury unless covered as part of the Preventive/Routine Care Benefit; 3.
for treatment of any injury or illness for which the covered individual is not under the regular care of a Physician or does not follow the attending Physician’s treatment plan; 4.
for expenses applied under this Plan toward satisfaction of any deductibles, copayments, benefit percentage or access charge; 5.
charges in excess of usual and reasonable for services and supplies; 6.
for treatment of any injury, illness or disability, resulting from or sustained as a result of being engaged in a felonious act as defined by Texas law regardless of whether arrested, indicted or convicted; 7.
for treatment of any injury, illness or disability resulting from or sustained as a result of war or act of war, declared or undeclared; 8.
for a covered individual where the primary carrier is a Health Maintenance Organization (HMO); 9.
for treatment of injuries resulting from covered individual’s participation in a riot or insurrection; 10.
for treatment of any illness, injury or disability which (1) was incurred while working for wage, hire, or monetary gain, or (2) could have been available if pursued under benefits for Workers’ Compensation whether or not the employer is a subscriber or non subscriber in a Workers’ Compensation Program and whether or not the injured person could have been lawfully covered by workers’ compensation as a volunteer. In applying this exclusion, work on the covered individual’s family farm or ranch is not considered an employment arrangement; 11.
for eye examinations for the purpose of prescribing corrective lenses or determining visual acuity or for treatment of refractive errors, eye glasses or contact lenses (including the fitting thereof), orthoptics, vision therapy, or other special vision procedures including but not limited to Radial Keratotomy (RK), Laser Assisted In‐Situ Keratomileusis (LASIK) and Excimer Laser Photorefractive Keratectomy (PRK); 12.
incurred in connection with remedying a condition by means of cosmetic surgery or non‐mastectomy reconstructive surgery, or a non‐lumpectomy reconstructive surgery, or in connection with a prophylactic mastectomy without a cancer diagnosis, or in connection with a primary prophylactic oophorectomy without an appropriate bilateral diagnosis, unless otherwise specifically covered under this plan; 14.
prophylactic procedures and/or testing due to family history, unless otherwise specifically covered under this plan; 15.
for vocational evaluation, rehabilitation or retraining; 16.
for custodial care or maintenance care; 17.
for any services furnished by any institution providing primarily convalescent or custodial care; 18.
for repair and maintenance or replacement of lost, missing or stolen Durable Medical Equipment, when previously purchased by the Plan, except when necessitated by physiological changes or accidental destruction, subject to approval by the Group Benefits Administrator; 19.
for home healthcare expenses that are for: a.
b.
c.
custodial care; transportation services; or any period during which the covered individual is not under the continuing care of Physician; 20.
for sex therapy, outpatient group family therapy, marriage counseling or any other social services unless otherwise specified; 21.
connected with the treatment of infertility and assisted reproductive technology including but not limited to artificial, in‐vitro, embryo transfer and insemination or any surgical procedure for the inducement of pregnancy; 22.
for elective abortions for covered individuals except in the case of incest, rape or situations which are life threatening to the mother; Benefit Facts Guide (Rev 8‐30‐11) 26 | Page 23.
for services related to intersex surgery (transsexual operations) and any resulting complications; 24.
for treatment, non‐surgical and surgical procedures to reverse sterilization; 25.
for personal comfort, convenience or safety items; including but not limited to, the purchase or rental of telephones; televisions; guest meals or cots; orthopedic mattresses; allergy‐free pillows, blankets and/or mattress covers; non‐hospital adjustable beds; waterbeds; structural changes to a house including tub rails and portable or fixed shower benches; purchase, rental or modification of motorized transportation equipment, including manual or electronic lifts; elevators; escalators; and ramps; 26.
for air purification, humidifying, cooling or heating equipment; 27.
for exercising equipment, vibratory equipment, swimming or therapy pools, health club memberships, massage therapy or hippo therapy; 28.
incurred in connection with acupuncture or acupressure; 29.
for educational testing, educational therapy, hypnosis, biofeedback, recreational therapy or any behavior modification and learning disability therapy. Nutritional education is covered per the Schedule of Medical Benefits; 30.
for spinography or thermography; 31.
for treatment of nicotine addiction or for any treatment, service or supply incurred or any therapy or training designed to curb or alleviate a personal habit; 32.
for any treatment of the temporomandibular joint (TMJ) or jaw‐related neuromuscular conditions not listed as an Eligible Benefit; 33.
for care or treatment to the teeth, alveolar processes, gingival tissue or for malocclusion and/or dental implants; 34.
for any drug therapy, treatment, or procedures meeting the definition of an Unproven Medical Procedure as defined in this booklet; 35.
for cosmetic hair loss treatment; 36.
for drugs labeled: "Caution ‐ limited by Federal law to investigational use" or experimental drugs; 37.
for drugs and medicines lawfully obtainable without a Physician’s prescription (even if prescribed by a Physician) including but not limited to vitamins, cosmetics, dietary supplements, nutritional formulas used as food replacement, over‐the‐counter home tests, sublingual allergy drops, homeopathic remedies and/or alternative remedies; 38.
for prescription drugs, supplies and equipment dispensed on an outpatient basis which are covered under a Prescription Drug Program (including lifestyle medications, copayments and any required payment differentials between generic and brand name drugs); 39.
for services rendered by any of the following relatives: a.
b.
c.
d.
e.
f.
g.
spouse; parent(s), step‐parent(s) or parent(s)‐in‐law; child (ren) or child(ren)‐in‐law; brother(s) or brother(s)‐in‐law; sister(s) or sister(s)‐in‐law; grandparent(s) or grandparent(s)‐in‐law; aunt(s) or uncle(s) or aunt(s)‐ or uncle(s)‐in‐law; 40.
for claims submitted by the Employee or Provider more than twelve (12) months from the date the expense was incurred, unless it was not reasonably possible to furnish the information within the filing deadline as determined by the Group Benefits Administrator, or within ninety (90) days after a decision is made by the employer’s workers’ compensation carrier or by the Workers’ Compensation Division of the Texas Department of Insurance, that the medical expense sought to be claimed is due to an injury that is non‐compensable, whichever is later. Determination of reasonably possible is at the sole discretion of the Group Benefits Administrator; 41.
for repair of hearing aids; 42.
for cryotherapy machine to deliver cold therapy for home use; 43.
for contraceptive devices including, but not limited to, IUD and Norplant; 44.
for expenses for treatment of conditions specifically excluded by the plan and for treatment or conditions incurred as a result of, or due to complications of a non‐covered expense whether medically eligible or not incurred initially and as a result of complications due to a non‐covered benefit under the Plan. This exclusion does not apply to pregnancy that is connected with the treatment of infertility and assisted reproductive technology including but not limited to artificial, in‐vitro, embryo transfer and insemination or any surgical procedure for the inducement of pregnancy; Benefit Facts Guide (Rev 8‐30‐11) 27 | Page 45.
for non‐custom molded foot orthotics; 46.
for treatment of developmental delays; 47.
for services, medication, devices and supplies relating to the treatment of erectile dysfunction, impotence and decreased libido; 48.
for medications purchased in a foreign country if purchased for non‐immediate services; 49.
for employer‐mandated immunizations, medical services, medical testing; 50.
for charges incurred as a result of travel outside of the United States or its territories specifically to receive medical treatment, unless otherwise specifically covered under this Plan; 51.
for virtual colonoscopies; 52.
for convalescent care; 53.
for infusion pumps for intralesional administration of narcotic analgesics and anesthetics and intra‐articular administration of narcotic analgesics and anesthetics; 54.
for treatment of any injury or illness during any extension of the time period of continuation of coverage which is attributable to the Employer’s failure under the law or as required by contract to give timely notice of a qualifying event; 55.
for treatment of any injury or illness during any time period following a lump sum or severance settlement of an employment termination unless continuation of coverage has been elected and then only for the time period required by law under continuation of coverage; 56.
for charges for internet medical management services and/or telemedicine, unless medical information is communicated in real‐
time with the use of interactive audio and video communications equipment, and is between the performing physician and a distant physician or health care specialist with the patient present during the communication; 57.
for expenses related to a surrogate pregnancy; 58.
exceeds (in scope, duration or intensity) that level of care which is needed; or 59.
for services or treatments that are excluded under any part of this Plan. Benefit Facts Guide (Rev 8‐30‐11) 28 | Page ELIGIBILITY AND COVERAGE Enrollment Requirements The names, social security numbers, sexes and birth dates of all persons in a family enrolling in the Plan will be provided to the Pool on an enrollment form or a change form signed and dated by the Employee and Employer and received by the Pool. Any person enrolling after the Employer’s initial enrollment will be considered a Late Entrant and will be subject to the Late Entrant Limitations. Employee To receive coverage, you must enroll within thirty‐one (31) days of the commencement of your employment. If you enroll, coverage will begin the later of: 1.
2.
the date you became an active Employee working at least twenty (20) hours per week; or the date you complete any waiting period established by your Employer. Employees must be enrolled within the initial enrollment period or wait until the next open enrollment period. During the Open Enrollment period, changes in enrollment may occur without a qualifying event. Eligible individuals who enroll during an Open Enrollment period will be Late Entrants under the Plan. Coverage will become effective on the date of the qualifying event and the Late Entrant limitation applies. If the new hire employee enrollment information and/or the Open Enrollment information is not received by TML IEBP within the designated plan document guidelines, the Employee may be enrolled as a Late Entrant if the Employer’s policy pays 100% of the Employee contribution and the Employer maintains 100% of the Employee participation requirement. Retiree 1.
2.
3.
To receive coverage, you must enroll within thirty‐one (31) days of the commencement of your retirement. If you enroll, coverage will begin the date you become a retiree. Upon retirement, if the covered individual enrolls in Continuation of Coverage the Retiree Medical Benefit will not be an option at the termination of Continuation of Coverage. Pool coverage is terminated upon Medicare eligibility age sixty‐five (65). Dependent Existing eligible Dependents must enroll and TML IEBP must receive an enrollment form within thirty‐one (31) days of the commencement of your employment. Dependents acquired after your eligibility date must be enrolled within thirty‐one (31) days of the date acquired. Your Dependents will be eligible for dependent coverage on the later of: 1.
the date you become covered; or 2.
the date a Dependent is added. Back‐dated and retroactive requests are not acceptable. Dependent coverage cannot be effective before the date employee coverage is effective. Please refer to the definition of Dependent in the definitions section of the booklet to determine who is eligible for Dependent coverage. Please refer to the Late Entrant definition if enrollment timelines are not met. If TML IEBP does not receive the Dependent information within the designated eligibility timeline specified, but the Employer Member provides TML IEBP with payroll documentation that contribution was deducted from the Employee’s paycheck appropriately, then TML IEBP will enroll the Dependent per the payroll documentation. Benefit Facts Guide (Rev 8‐30‐11) 29 | Page The Group Benefits Administrator may request written proof of the eligibility of any Dependent other than a spouse or natural child. In special circumstances, the Group Benefits Administrator, in its discretion, may request written proof that a spouse or natural child is an eligible Dependent. These requests are to verify eligibility and to determine if this Plan is primary or secondary. Proof of a properly filed declaration of informal marriage will be necessary for an informal marriage to be recognized by the Plan. Active Duty Reservists Active duty reservists or guard members and their covered Dependents can maintain eligibility on the Plan for up to twenty‐four (24) months as prescribed by and subject to the terms and conditions of the Uniformed Services Employment and Reemployment Rights Act (USERRA). The date on which the person’s absence begins is the qualifying event for Continuation of Coverage (COC) to be offered to the reservist or guard member. If a fire fighter or police officer is called to active duty for any period, the employing municipality must continue to maintain any health, dental or life coverage received on the date the fire fighter or police officer was called to active military duty until the municipality receives written instructions from the fire fighter or police officer to change or discontinue the coverage. Such instruction shall be provided no later than sixty (60) days following the Qualifying Event. If no such instruction is given, then coverage will terminate on the sixty‐first (61st) day, which shall then become the Qualifying Event for COC purposes. Eligibility will meet or exceed requirements of USERRA and/or regulatory compliance. In administering this coverage, TML IEBP will follow the time guidelines of Continuation of Coverage under 42 U.S.C.A. 300bb‐1 et seq. To qualify for this coverage, the Employee must give written notice to the Employer within sixty (60) days of the qualifying event. The Employer Member must notify TML IEBP that an Employee has been called to active duty and submit a copy of the Employer Member’s Active Reservist Policy. If the Employee will be on active duty for thirty‐one (31) days or less, the Employer Member will keep the Employee on the plan with no change in coverage. If the Employee will be on active duty for more than thirty‐one (31) days, the Employer Member will notify TML IEBP of the qualifying event. If TML IEBP administers Continuation of Coverage, the Employer Member must notify TML IEBP by sending a Qualifying Event Notice and mark the qualifying event “Called to Active Duty.” If the Employer Member administers their own Continuation of Coverage, the Employer Member must notify TML IEBP of the termination if call to active duty is more than thirty‐one (31) days. The Employer Member is responsible for all required notices. For the Employee nineteen (19) years of age or older to return to the Employer Member’s plan and continue their benefits with no waiting period or pre‐existing condition the Employee must return to work within the time period required by state and federal law for such return. The additional 2% of contribution is not charged for an Employee called to active duty. Newborn Children If you acquire a newborn child, an enrollment form for the newborn for Dependent coverage must be completed and received by the Group Benefits Administrator within sixty (60) days of the birth. Coverage for the newborn will be effective on the date of the birth. The fact that you have other dependent children or a spouse covered does not automatically extend coverage to a newborn. Late Entrants/Open Enrollment Late Entrants will only be accepted for coverage: 1.
2.
3.
4.
during the Plan’s annual open enrollment; within thirty‐one (31) days of a qualifying event; if initial or open enrollment occurs and eligibility information is received by TML IEBP between thirty‐two (32) days and sixty (60) days after commencement of employment, the Employer Member must maintain 100% participation in TML IEBP Plan and the Employer Member must pay 100% of the Employee’s cost of coverage; or if an employee who is eligible, but not enrolled, for coverage under the terms of the plan (or a dependent of such an employee if the dependent is eligible, but not enrolled for coverage under such terms) enrolls for coverage under the terms of the plan within sixty (60) days of loss of coverage, due to loss of eligibility, under Medicaid or a State Children’s Health Insurance Program (SCHIP) or within sixty (60) days of becoming eligible for group health payment assistance through Medicaid or SCHIP. Benefit Facts Guide (Rev 8‐30‐11) 30 | Page A late enrollment is any nineteen (19) years of age or older individual enrollment, which occurs on or after the group’s initial enrollment date if the individual was not covered on the Employer Member’s prior plan. Coverage for these Late Entrants will be effective beginning on the first day of the month following the Open Enrollment and the pre‐existing condition limitation applies. During the plan year, certain qualifying events will permit an Employee to add a Dependent(s) other than during Open Enrollment. Documentation must be submitted when requested. These qualifying events are as follows: 1.
marriage; 2.
birth, adoption or placement for adoption of a child; 3.
loss of coverage, due to loss of eligibility, under Medicaid or SCHIP; 4.
becoming eligible for group health payment assistance through Medicaid or SCHIP; 5.
termination of a spouse’s employment; 6.
your spouse changes from full‐time to part‐time employment; 7.
your spouse takes an unpaid leave of absence; or 8.
significant change (10% or more) in the benefit coverage of your spouse’s health plan. Employees must enroll the eligible Dependent(s) within thirty‐one (31) days of the qualifying event (sixty (60) days if the qualifying event is the birth or adoption of a child or the loss of coverage under Medicaid or SCHIP) or wait until the next Open Enrollment period. The pre‐
existing condition limitation applies to Late Entrants nineteen (19) years of age or older. If the qualifying event is a loss of coverage under another plan or a significant change in the coverage under another plan and/or if the qualifying event is marriage, placement for adoption of a child, divorce, or death, the Employee many enroll any eligible dependent within thirty‐one (31) days of the qualifying event. Other Issues Affecting Eligibility And Coverage Changes Requiring Notification The following events may affect dependent coverage. You are required to notify the Pool in these events: 1.
marriage; 2.
birth, adoption or placement for adoption of a child; 3.
divorce of the Covered Employee; or 4.
death of the Covered Employee. You must notify your employer if you wish to voluntarily drop dependent coverage. Any drop of a Dependent regardless of whether the coverage is paid for pursuant to pre‐tax or post‐tax payroll deduction will only be allowed following a qualifying event as prescribed by the Internal Revenue Service regulations and on these conditions: 1.
any change in coverage must be consistent with the qualifying event; and 2.
the Group Benefits Administrator is notified in writing within thirty (30) calendar days of the events. Once a Dependent has been dropped, he or she will become a Late Entrant on re‐enrollment and is subject to the pre‐existing condition limitations if the dependent is nineteen (19) years of age or older. Forms for reporting these changes are available from your employer. Mentally or Physically Handicapped Children If a child of a covered individual attains the age of twenty‐six (26) (at which time coverage would normally terminate) but the child is mentally or physically incapable of supporting themselves and primarily dependent upon you for support, coverage may be continued. You must submit satisfactory proof of the child's incapacity to the Group Benefits Administrator within thirty‐one (31) days of the date the child attains the age of twenty‐six (26). Coverage may continue for such child as long as the incapacity continues, subject to payment of the required contribution and all other terms of the Plan. The Group Benefits Administrator may require satisfactory proof of the continued incapacity documented as a disability by the Social Security Administration (SSA). The Group Benefits Administrator may have a physician examine the child or may request proof to confirm the incapacity, but not more often than once a year. If you fail to submit proof when reasonably required or refuse to allow the Group Benefits Administrator to have the child examined, then coverage for the child will terminate. Benefit Facts Guide (Rev 8‐30‐11) 31 | Page CONTINUATION OF COVERAGE (COC) RIGHTS UNDER COBRA Introduction You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA Continuation of Coverage (COC), which is a temporary extension of coverage under the Plan. This notice generally explains Continuation of Coverage when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to Continuation of Coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Continuation of Coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan booklet or contact TML IEBP, 1821 Rutherford Lane, Suite 300, Austin, Texas 78754, (800) 282‐5385. What is Continuation of Coverage? Continuation of Coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, Continuation of Coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect Continuation of Coverage may be required to pay depending on the policy of your employer. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens: 1.
your hours of employment are reduced; or 2.
your employment ends for any reason other than your gross misconduct. If you are the spouse of the employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens: 1.
your spouse dies; 2.
your spouse’s hours of employment are reduced; 3.
your spouse’s employment ends for any reason other than his or her gross misconduct; 4.
your spouse becomes entitled to Medicare benefits (under Part A, Part B and/or Part C); or 5.
you become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens: 1.
the parent‐employee dies; 2.
the parent‐employee’s hours of employment are reduced; 3.
the parent‐employee’s employment ends for any reason other than his or her gross misconduct; 4.
the parent‐employee becomes entitled to Medicare benefits (Part A, Part B and/or Part C); 5.
the parents become divorced or legally separated; or 6.
the child stops being eligible for coverage under the Plan as a “dependent child.” Sometimes, filing a proceeding in bankruptcy under Title II of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to your employer and the bankruptcy results in the loss of coverage for any retired employee covered under the Plan, the retired employee will become a qualified beneficiary with respect to the bankruptcy. The retired employee’s spouse, surviving spouse and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. Please note that Continuation of Coverage does not include any life benefits. If you had voluntary life coverage, you may convert it to an individual policy within thirty‐one (31) days of your qualifying event. Contact your employer’s human resources office for more information and conversion forms. Benefit Facts Guide (Rev 8‐30‐11) 32 | Page When is Continuation of Coverage available? The Plan will offer Continuation of Coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, commencement of a proceeding in bankruptcy with respect to the employer or the employee’s becoming entitled to Medicare benefits (under Part A, Part B and/or Part C), the employer must notify TML IEBP of the qualifying event. You must give notice of some Qualifying Events For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within sixty (60) days after the qualifying event occurs. If TML IEBP is the Plan Administrator, you must provide this notice to: TML IEBP, 1821 Rutherford Lane, Suite 300, Austin, Texas 78754, (800) 282‐
5385. How is Continuation of Coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, Continuation of Coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect Continuation of Coverage. Covered employees may elect Continuation of Coverage on behalf of their spouses, and parents may elect Continuation of Coverage on behalf of their children. Continuation of Coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee’s becoming entitled to Medicare benefits (Part A, Part B and/or Part C), your divorce or legal separation or a dependent child’s losing eligibility as a dependent child, Continuation of Coverage lasts for up to a total of thirty‐six (36) months. When the qualifying event is the end of the employment or reduction of the employee’s hours of employment, and the employee became entitled to Medicare benefits less than eighteen (18) months before the qualifying event, Continuation of Coverage for qualified beneficiaries other then the employee lasts until thirty‐six (36) months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare eight (8) months before the date on which his employment terminates, Continuation of Coverage for his spouse and children can last up to thirty‐six (36) months after the date of Medicare entitlement, which is equal to twenty‐eight (28) months after the date of the qualifying event (thirty‐six (36) months minus eight (8) months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, Continuation of Coverage generally lasts for only up to a total of eighteen (18) months. There are two ways in which this eighteen (18) month period of Continuation of Coverage can be extended. Disability extension of eighteen (18) month period of Continuation of Coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify TML IEBP within sixty (60) days of that determination, you and your entire family may be entitled to receive up to an additional eleven (11) months of Continuation of Coverage for a total maximum of twenty‐nine (29) months. The disability would have to have started at some time before the sixtieth (60th) day of Continuation of Coverage and must last at least until the end of the eighteen (18) month period of Continuation of Coverage. Second Qualifying Event extension of eighteen (18) month period of Continuation of Coverage If your family experiences another qualifying event while receiving eighteen (18) months of Continuation of Coverage, the spouse and dependent children in your family may get up to eighteen (18) additional months of Continuation of Coverage, for a maximum of thirty‐six (36) months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving Continuation of Coverage if the employee or former employee dies, becomes entitled to Medicare benefits (Part A, Part B and/or Part C) or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Adding Dependents If you are a Continuation of Coverage participant, you have the same rights to add dependents to your Continuation of Coverage as an active covered employee. For example, you may add dependents to your Continuation of Coverage within thirty‐one (31) days of marriage or the birth, adoption or placement for adoption of a child. Also, you may add dependents to your Continuation of Coverage during your employer’s Open enrollment. However, these dependents who were not covered under the Plan before your qualifying event occurred are not qualified beneficiaries and do not have individual Continuation of Coverage rights, except for children added within thirty‐one (31) days of birth, adoption or placement for adoption. Children added to your Continuation of Coverage within thirty‐one (31) days of birth, adoption or placement for adoption are qualified beneficiaries and have their own Continuation of Coverage rights. Benefit Facts Guide (Rev 8‐30‐11) 33 | Page If you have questions Questions concerning your Plan or your Continuation of Coverage rights should be addressed to the contact or contacts identified below. State and local government employees seeking more information about their rights under COBRA Continuation of Coverage, the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans, can contact the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services at www.cms.gov/COBRAContinuationofCov or [email protected]. Keep Your Plan Informed of Address Changes In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Contact Information TML Intergovernmental Employee Benefits Pool 1821 Rutherford Lane, Suite 300 Austin, Texas 78754 Phone: Customer Service: Medical Care Management: Spanish Line: (512) 719‐6500 (800) 282‐5385 (800) 847‐1213 (800) 385‐9952 Benefit Facts Guide (Rev 8‐30‐11) 34 | Page COVERAGE PERIOD MEASURED FROM QUALIFYING EVENT DATE Benefits subject to COC: Medical, HRA coverage that is in conjunction with Major Medical, ERISA EAP Plans (health benefits only), Dental, Vision and Rx Benefits not subject to COC: Life, LTD, STD and EAP (non‐health benefits) Qualifying Events: Covered Employee’s Termination/Reduction in Hours/Death Benefit Facts Guide (Rev 8‐30‐11) 35 | Page CONSUMER DIRECTED PLANS Consumer Directed Plans are relatively new types of health plans designed to give you more control over your health‐care spending. Consumer Driven Health Plans have many of the features of traditional plans, but also include an account you manage yourself. The current choices include: •
Flexible Spending Account (FSA): With an FSA, employee designated money is deducted from payroll, pre‐taxed and put into a Section 125 eligible benefit account. You may access the money to pay for health related eligible services and benefits as well as eligible expenses for your dependents, capital expenditures and/or premium payments. The IRS determines which expenses are covered so check to see what’s allowable either through you plan administrator or through the IRS Web site at www.irs.gov/publications/p502/index.html. The list of covered expenses is quite extensive. Prepare your personal health record file for the collection of receipts. FSAs have a “use it or lose it” provision, meaning that if you don’t use all the money you put into the account by the end of the plan year, your employer will keep the excess funds. (Some plans may implement a 2 month 15 day grace period). •
Health Savings Account (HSA): To open an HSA, your health plan has to qualify as a high‐deductible plan. The good news is that if it is, you can use funds from your account to pay for deductible expenses. If you qualify to open an HSA, you can deduct your contributions from you income tax or contribute pre‐tax dollars from your paycheck if your employer has a cafeteria plan (also known as an IRS 125 plan) that offers a choice of benefit options. You may also add in a contribution from your employer, and have your spouse contribute funds. The amount of annual deposits to your account is limited under IRS guidelines, so check with your employer to identify your contribution limits. Your HSA money, which you may be able to invest in a variety of funds, earns tax‐free interest and is available to you whenever you need the funds. You can take the account with you if you change jobs and let the balance keep growing as long as you like. No rule exists that says you have to spend HSA dollars for health‐care costs. You can usually withdraw cash from your account; although if you spend the money on non‐qualified expenses, the withdrawal will be taxable and you may have to pay additional penalties. You may want to save your HSA dollars for a big health expense (perhaps having a baby or having extensive dental work. •
Health Reimbursement Arrangement (HRA): Your employer funds an HRA. You use the money to pay deductibles and eligible medical expenses. Per the plan document, HRA funds may roll from one plan year to the next. Your employer may provide a Retiree Reimbursement Account (RRA) that is activated upon employer defined retiree benefits. Health Flexible Spending Account Any employee of an employer that offers health FSAs and meets the employer's eligibility requirements, if any. Health Reimbursement Account Any employee of an employer that offers an HRA and meets the employer's eligibility requirements, if any. Usually, from an employee's own paycheck based upon an election made by the employee to reduce his or her compensation. Employers, can, however, fund health FSAs if they choose. Employers only. At no time do employees fund HRAs. Who Can Have One? Where Does the Money Come From? Benefit Facts Guide (Rev 8‐30‐11) Health Savings Account Any taxpayer who 1) is covered by a qualifying high‐
deductible health plan with no other disqualifying coverage, 2) is not eligible for Medicare and 3) cannot be claimed as a tax dependent by any other taxpayer. There is no requirement that an HSA accountholder be employed by an employer that offers HSAs. Technically, anyone can fund someone's HSA, but usually the accountholder does it on his or her own. In many cases, employers will fund their employees' HSAs. Dependent Care (DCAP) Any employee of an employer that offers DCAPs and meets the employer's eligibility requirements, if any. Usually, from an employee's own paycheck based upon an election made by the employee to reduce his or her compensation. Employers, can, however, fund DCAPs if they choose.. 36 | Page Health Flexible Spending Account Employees can lower their taxable income. Employers can save on FICA and FUTA taxes (sometimes known as "payroll taxes") Health Reimbursement Account Employers can deduct HRA reimbursements from their taxes. Any qualified medical expense under the Internal Revenue Code. The key is that the expense must be primarily for medical care. Expenses that are primarily for cosmetic care or treatment will not qualify. Over‐the‐counter medications will qualify. Insurance contributions, however, will not qualify under any circumstance. NOTE: Employers may limit health FSAs to cover fewer expenses than what the IRS allows, but never more. This is entirely up to the employer so long as the allowable expenses are qualified medical expenses under the Internal Revenue Code. The key is that the expense must be primarily for medical care. Expenses that are primarily for cosmetic care or treatment will not qualify. Over‐the‐counter medications will qualify. Also, in many instances, health insurance premiums will qualify for reimbursement by an HRA. What Are the Tax Benefits? What Can the Money Be Used For? Benefit Facts Guide (Rev 8‐30‐11) Health Savings Account This depends on who contributes to the HSA and how it is contributed to. If an HSA is funded by an individual in the "standard" fashion (such as depositing a check into his or her HSA) then the accountholder will be able to make an "above‐
the‐line" deduction on his or her income taxes. If the individual is able to fund the HSA via an employer's cafeteria plan (like he or she funds an FSA), then the accountholder can reduce taxable income. If an employer makes a contribution to an employee's HSA, the employer can deduct it from its own taxes. Any qualified medical expense under the Internal Revenue Code. The key is that the expense must be primarily for medical care. Expenses that are primarily for cosmetic care or treatment will not qualify. Over‐the‐counter medications will qualify. Insurance premiums, however, will generally not qualify except in limited circumstances, such as COBRA premium payments, long‐term care insurance, deductible health insurance for accountholders 65 or over and any health plan maintained while receiving unemployment compensation. If the employee uses withdrawn cash for non‐medical purposes, the money so used becomes taxable income. NOTE: Unlike with health FSAs, employers may not limit their employees' HSAs to cover fewer expenses than what the IRS allows. Dependent Care (DCAP) Employees can lower their taxable income. Employers can save on FICA and FUTA taxes (sometimes known as "payroll taxes") Care provided to a dependent while the DCAP participant (and spouse, if any) is engaged in gainful employment or the pursuit thereof. The care must be primarily "custodial" in nature. Ask this question: is the main reason the dependent is getting the "care" to be taken care of (such as a regular day camp) or is it something else (such as a basketball day camp)? If it's the first, probably OK. If the second, probably not, although we will consider special circumstances. Note: Preschool expenses will almost always be OK; kindergarten and up school expenses will never be OK. 37 | Page Health Flexible Spending Account There is no IRS limit on the amount of money someone can put into his or her health FSA each year; however, many employers establish a limit. Health Reimbursement Account There is no IRS limit on the amount of money available through an HRA; however, most employers establish such a limit. Technically, the employer, but really the employee has ultimate control, since it's his or her money to begin with and he or she can choose how to spend it within employer‐set limits. Also, the employee has the right to the full amount of his or her annual election from day one. However, if the money is not used by the end of the plan year, it is forfeit back to the employer ("use‐it‐or‐lose‐it"). Yes. Often, it is a calendar year, though any 12‐month period will do. There are occasionally "short plan years" declared by employers in rare circumstances. The employer. Actually, while the word "account" is often used with regard to HRAs, that's not exactly correct. What an HRA really is a sort of promise to pay a certain amount as the need arises. Think of is as a sort of reverse allowance from a parent: "Go out to the movies and whatever, son, and then when you come back home I'll reimburse you for what you spent up to $50 (or some other amount)." Usually, yes. However, there is no requirement for this. The period of coverage can be in weeks or months, but never longer than a year. Yes, but only because of changes in status specified by IRS regulation, including change in marital status, change in number of dependents or dependent eligibility, change in employment status, change in residence, and changes regarding adoption or adoption proceedings. No. Although you may still have access to it in certain circumstances, such as if you elected COBRA or if you are submitting a claim for an expense incurred while employed. N/A Are There Annual Limits? Who Actually Controls the Money? Are There "Plan Years" for…? Can Participants Change Their Elections Mid‐
Year? Can You Take the Money With You When You Leave Employment? Benefit Facts Guide (Rev 8‐30‐11) No. Although you may still have access to it in certain circumstances, such as if you elected COBRA or if you are submitting a claim for an expense incurred while employed. Also, some employers may design their HRAs so that former Dependent Care (DCAP) There has been some Yes, and they will change from year to year. For 2009, confusion here, so note the following carefully. An the maximum contribution unmarried parent is shall be $3,000 for limited to $5,000 per year. accountholders with single Married couples filing insurance coverage or the amount of the deductible of jointly are also limited to $5,000. This is a the coverage, whichever is lower. For those with family "combined" limit, meaning that the husband coverage, the maximum is and wife's DCAPs together $5,950 or the deductible cannot exceed $5,000. whichever is lower. Accountholders approaching Only married couples filing separately are retirement age can also limited to $2,500 each. contribute another $1,000. The money must be held by Technically, the employer, but really the employee a trustee who is almost has ultimate control, since always a bank or insurance it's his or her money to company. The begin with and he or she accountholder may withdraw any and all monies can choose how to spend it within employer‐set in his or her HSA from the moment they are deposited limits. from any source. The account therefore survives loss of employment. Health Savings Account Sort of. If the HSA is funded through a cafeteria plan mechanism, there is a "plan year" of sorts, although elections can be changed at any time for HSAs. The more important factor for HSAs is the calendar year which will provide the maximum contribution one can make to an HSA. Yes for any reason. Yes. Yes. Often, it is a calendar year, though any 12‐
month period will do. There are occasionally "short plan years" declared by employers in rare circumstances. Yes in some circumstances, including all of those listed under health FSA. There are a few other exceptions as well, but are very fact‐
specific and will have to be handles on a case‐by‐
case basis. No. 38 | Page Can the Money Rollover from Year to Year? Do You Have Access to All of the Money for the Year at the Beginning of the Year? Does COBRA Continuation Coverage Apply To...? Can You Have an HSA with…? Health Flexible Spending Account Health Reimbursement Account employees can "spend‐down" their accounts after they leave. Furthermore, some employers may design "retiree HRAs" which allow retirees to access HRA‐like money upon retirement. No. Although if the employer allows for a two‐
and‐a‐half month "grace period," money from the previous plan year can be used for claims incurred during the current plan year. Yes, if the employer allows for this. Yes. Yes. This is called the "Uniform Coverage Rule". If the employer desires, yes. Generally the employee has access only to money that is already deposited in the account. Generally the employee has access only to money that is already deposited in the account. Yes, if the employee has not "overspent" his or her account at the time of the qualifying event. Yes. No. HSAs are usually not considered to be health plans. No. COBRA only applies to health plans. Yes, but only if the health FSA is limited to certain permitted coverage, such as vision and/or dental, or if the health FSA has a HDHP‐
like deductible (this would be extremely rare). Yes, but only if the HRA is limited to certain permitted coverage, such as vision and/or dental, or if the HRA has a HDHP‐like deductible. N/A Yes. There is no relationship between DCAPs and HSAs. Benefit Facts Guide (Rev 8‐30‐11) Dependent Care (DCAP) Health Savings Account No. Although if the employer allows for a two‐and‐a‐half month "grace period," money from the previous plan year can be used for claims incurred during the current plan year. No. DCAPs are pay‐as‐
you‐go. 39 | Page GOVERNMENT PROGRAMS Medicaid This government program provides a range of medical benefits to low‐income families, families receiving Temporary Assistance for Needy Families (TANF), and people drawing income support under Supplemental Security Incomes (SSI) Who is Eligible? •
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Pregnant women with limited incomes (married or single) and their children Children and teenagers from limited‐income families, some states cover children up to age 21 Families on welfare with children under age 18 Those 65 and older with limited incomes and who are terminally ill, blind, or disabled Certain people (pregnant women, children under 18, those over 65, and those who are blind or disabled) who have high medical bills they cannot afford Federal Employee Health Benefits Program (FEHBP) Health coverage for current and retired Federal employees and covered family members. If you join a Medicare drug plan, you can keep your FEHBP plan, and your plan will let you know who pays first. For more information, contact the Office of Personnel Management at 1.888.767.6738 or visit www.opm.gov/insure. Tricare (Military Health Benefits) Health care plan for active‐duty service members, retirees, and their families. Most people with TRICARE who are entitled to Part A must have Part B to keep TRICARE prescription drug benefits. If you have TRICARE, you aren’t required to join a Medicare Prescription Drug Plan. If you do, your Medicare drug plan pays first and TRICARE pays second. If you join a Medicare Advantage Plan with prescription drug coverage, TRICARE won’t pay for your prescription drugs. For more information, call the TRICARE pharmacy contractor at 1.877.363.8779 or visit www.tricare.mil. CHIP for Children The Children’s Health Insurance Program (CHIP) offers Medicaid benefits to children in families who earn too much to qualify for Medicaid but not enough to buy health insurance on their own. For more information, visit: http://www.insurekidsnow.gov/states.asp State High‐Risk Pools Once COBRA benefits run out, about two‐thirds of the states offer uninsured Americans with pre‐existing conditions the opportunity to purchase healthcare coverage through state high‐risk pools. These plans can be similar to catastrophic and high‐deductible health plans. The drawbacks: they can be more expensive than the few private insurance plans that cover pre‐existing conditions and the waiting list is long. For more information, visit the National Association of State Comprehensive Health Insurance Plans at http://www.naschip.org Free or Low‐Cost Health Centers The US Health Resources and Services Administration (HRSA) sponsors this federal health center program designed for all uninsured and low‐income Americans. It is composed of federally funded health centers that can be found in every state. •
Individuals who walk in and apply and are accepted, pay what they can afford, based on income •
Centers provide checkups for well patients, treatment for ill patients, and complete pregnancy care •
Centers provide children’s routine‐checkups and immunizations, family dental care, prescription drug needs, and mental health and substance‐abuse care To find a health center in your area, visit: Http://finadahealthcenter.hrsa.gov Federal Health Programs for Native Americans The US Department of Health and Human Services offers the “Indian Health Service” (IHS) for American Indians and Alaskan native tribes. Medical programs include specialty programs, medical support resources, and public health and wellness programs. For more information, visit http://www.ihs.gov Healthcare for Veterans’ Benefits Unemployed veterans and their dependents can enroll in the Veterans Affairs medical Care Hardship program, which provides healthcare services, helps pay co‐pays, and in some cases, waives any existing healthcare debts. For more information visit http://www.va.gov/healtheligiblity/costs/Hardship.asp Benefit Facts Guide (Rev 8‐30‐11) 40 | Page Medicare Options Medicare is an option for healthcare coverage for individuals ages 65 and older and certain disabled people at a younger age. In recent years, there have been some alternatives for the traditional Medicare coverage. •
Part A (hospital insurance) covers inpatient hospital care and rehabilitation, nursing facilities, hospice, and home healthcare •
Part B (medical insurance) covers “necessary medical services,” •
Part C (Medicare Advantage) covers same services at Parts A and B, but coverage is provided a private insurance company, not the government •
Part D (prescription coverage) Here are the basics: Those who contributed to Social Security will likely not pay anything for Medicare Part A You must pay premiums for Part B. The government automatically deducts the part B premium from your Social Security Check if you have started collecting Social Security Coverage is subject to various deductibles, coinsurance, co‐pays, and certain limitations, such as first‐day deductibles for you first day in the hospital •
You can choose your own doctor and other providers •
Coverage does not include prescription drugs •
Medicare covers any pre‐existing condition For more information contact http://www.ssa.gov/pgm/links_medicare.htm or http://www.medicare.gov or call 1‐800‐MEDICARE (1.800.633.4227) Medicare Advantage (also known as Medicare Part C) This alternative to traditional Medicare is offered by many private insurance companies and includes hospital and medical insurance similar to that of Medicare Parts A and B. Medicare Advantage plans cover pre‐existing conditions, such as diabetes and asthma, for example. If you join a Medicare Advantage plan, you may have lower out‐of‐pocket costs and broader coverage than traditional Medicare. Some Medicare Advantage plans even include prescription drug coverage. Here are key features of Medicare Advantage plans You are still responsible for paying the same premium as with traditional Medicare Part B Depending on the Medicare Advantage plan you select, you might also have to pay additional premiums Some of these plans also have out‐of‐pocket costs, including co‐pays Depending on the plan (e.g. HMO, PPO), you will have to use in network providers and may need referrals for some medical services. There are many different Medicare Advantage Plans Medicare Advantage plans include health maintenance organization (HMO) plans, preferred provider organization (PPO) plans, and private fee‐for‐service (PFFS) plans. The lease expensive and most common is Medicare HMO. Medicare HMOs give you coverage similar to Medicare Parts A and B, but your care is limited to doctors within the HMO network. To find Medicare Advantage coverage insurance, check with private insurance providers. Medicare Part D Medicare Part D provides prescription coverage if you are enrolled in Medicare or Medicare Advantage Plans. There are different formularies and other limitations in Part D plans. For more information on Medicare Part D, visit: http://www.medicare.gov or call 1‐800‐
MEDICARE (1.800.633.4227) Medigap: Covers gaps left by Medicare coverage Private insurance companies offer Medigap programs, also known as “Medicare Supplemental Insurance, “ which cover what traditional Medicare does not, such as co‐pays, coinsurance, and deductibles. There are a number of different Medigap program options, from basic to comprehensive. Medigap policies expand your traditional coverage and also eliminate first‐day deductibles for hospital stays. Medigap policies can no longer be sold with prescription drug coverage, but if you have drug coverage under a current Medigap policy, you can keep it. However, it may be to your advantage to join a Medicare drug plan because most Medigap drug coverage isn’t creditable. Benefit Facts Guide (Rev 8‐30‐11) 41 | Page OTHER PRIVATE INSURANCE Employer or Union Health Coverage ‐ Health coverage from your spouse’s or other family member’s current or former employer or union. If you have prescription drug coverage based on your current or previous employment, upon age sixty‐four your employer or union will notify you each year to let you know if your drug coverage is creditable. Keep the information you get. Call your benefits administrator for more information before making any changes to your coverage. COBRA ‐ A Federal law that may allow you to temporarily keep employer or union health coverage after the employment ends or after you lose coverage as a dependent of the covered employee. STEPS TO DECIDE BEST MEDICARE OPTION Step I Decide if you want the Original Medicare or a Medicare Advantage Plan. •
Original Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) •
Medicare Advantage Plan (Like an HMO or PPO) Includes Both Part A (Hospital Insurance) and Part B (Medical Insurance) Note: If you join a Medicare Advantage Plan, you do not need a supplemental policy. Step II Decide if you want Prescription Drug Coverage. Step III Decide if you want Supplemental Coverage that fills gaps in original Medicare coverage. Benefit Facts Guide (Rev 8‐30‐11) 42 | Page MEDICARE ELIGIBILITY, ENROLLMENT AND ENTITLEMENT Source: Centers for Medicare and Medicaid Services, IRS final COBRA regulations Medicare A Medicare B Hospital Insurance Medical Insurance Medicare C Medicare D +Choice/Medicare Advantage Plan Prescription Benefit ELIGIBILITY FOR PREMIUM‐FREE PART A An individual is eligible for premium‐free Medicare Part A (Hospital Insurance) if: 
He or she is 65 or older and is receiving, or is eligible for retirement benefits from Social Security or the Railroad Retirement Board; 
He or she is under 65 and has received Social Security or Railroad Retirement disability benefits for the prescribed time and meets the Social Security Act disability requirements; 
The individual or spouse had Medicare covered government; or 
He or she is under 65 and has end‐stage renal disease (ESRD). ELIGIBILITY FOR PART A, WITH PREMIUM Individuals not eligible for premium‐free Medicare Part A can buy Part A by paying a monthly premium if they are: 
Age 65 or older; 
Disabled and returned to work; 
Enrolled in Part B; and 
A resident of the United States, and either a citizen or an alien lawfully admitted for permanent residence who has lived in the United States continuously during the five years immediately before the month in which they apply. ENROLLMENT FOR PART A Individuals have four periods to enroll in premium Part A: 
Initial Enrollment Period‐Three months before they first meet all Medicare eligibility requirements and continuing for three months after 65th birthday. 
General Enrollment Period‐January 1 through March 31 of each year. 
Special Enrollment Period‐This period is for people who did not take premium Part A during there initial enrollment period because they or their spouse currently work and have group health coverage. They can sign up for premium Part A at any time they are covered under the group health plan based on current employment. If the employment or group health coverage ends, they have eight months to sign up. 
Transfer Enrollment Period‐This period is for people age 65 or older who have Part B only and are enrolled in a Medicare managed care plan. They can sign up for premium Part A during any month in which they are enrolled in a Medicare managed care plan. If they leave the plan or if the plan coverage ends, they have eight months to sign up. PART A: HOSPITAL INSURANCE 
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Usually do not pay a monthly premium for Part A coverage if the individual or their spouse paid Medicare taxes while working. You may be able to buy Part A if you are not eligible. In most cases individuals buying Part A must also have Part B. PART A COVERED SERVICES 
Blood: In most cases, the hospital gets blood from a blood bank at no charge, and individual will not have to pay for it or replace it. If the hospital has to buy blood, the individual must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by someone else. 
Home Health Services: Limited to medically‐necessary part‐time or intermittent skilled nursing care, or physical therapy, speech‐
language, pathology, or a continuing need for occupational therapy. A doctor must order the care, and a Medicare‐certified home health agency must provide it. Home health services may also include medical social services, part‐time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. The individual must be homebound, which means that leaving home is a major effort. 
Hospice Care: For people with a terminal illness. Your doctor must certify that the individual expected to live 6 months or less. Coverage includes drugs for pain relief and symptom management; medical, nursing, social services; and other covered services Benefit Facts Guide (Rev 8‐30‐11) 43 | Page 
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as well as services Medicare usually does not cover, such as grief counseling. A Medicare‐approved hospice usually gives hospice care in the home (or other facility like a nursing home). Medicare covers some short‐term inpatient stays for pain and symptom management that cannot be addressed in the home. These stays must be in a Medicare‐approved facility, such as a hospice facility, hospital, or skilled nursing facility. Medicare also covers inpatient respite care which is care given in Medicare approved facility so that the usual caregiver can rest. The individual can stay up to five days each time they get respite care. Medicare will pay for covered services for health problems that are not related to terminal illnesses. An individual can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies that they are terminally ill. Hospital Stays (Inpatient): Includes semi‐private room, meals, general nursing, drugs as part of inpatient treatment, and other hospital services and supplies. Examples include inpatient care your get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long‐term care hospitals, inpatient care as part of a qualifying clinical research study and mental health care. This does not include private‐duty nursing, a television or telephone in a room (if there is a separate charge for these items), or personal care items like razors or slipper socks. It also does not include a private room, unless medically necessary. Part B covers the doctor and emergency room services provided while in a hospital setting. Skilled Nursing Facility Care: Includes semi private room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a three day minimum inpatient hospital stay for a related illness or injury). To qualify for care in a skilled nursing facility, the doctor must certify that daily skilled care like intravenous injections or physical therapy is needed. Medicare does not cover long‐term care or custodial care in this setting. ELIGIBILITY FOR PART B Individuals are automatically eligible for Part B (Medical Insurance) if they are eligible for premium‐free Part A. Individuals are also eligible for Part B if they are not eligible for premium‐free Part A, but are age 65 or older and either a citizen or an alien lawfully admitted for permanent residence who has lived in the United States continuously during the five years immediately before the month during which they enroll in Part B. 
He or she is 65 or older and is receiving, or is eligible for retirement benefits from Social Security or the Railroad Retirement Board; 
He or she is under 65 and has received Social Security or Railroad Retirement disability benefits for the prescribed time and meets the Social Security Act disability requirements; 
The individual or spouse had Medicare covered government; or 
He or she is under 65 and has end‐stage renal disease (ESRD). PART B: MEDICAL INSURANCE Most people will pay the standard premium amount for Part B premium, unless you have a modified gross income as reported to the IRS on your tax return from two years ago is above a certain amount, you may pay more. Your modified adjusted gross income is your taxable income plus your tax exempt interest income. Social Security will notify you if you have to pay more than the standard premium. If you have to pay a higher amount for your Part B premium and you disagree call Social Security at 1.800.772.1213. TTY users should call 1.800.325.0778. PART B COVERED SERVICES There are two kinds of Part B covered services. 
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Medically Necessary Services ‐ services or supplies that are needed to diagnose or treat medical conditions that meet accepted standards for medical practice. Preventive Services ‐ Health care to prevent illness or detect it at an early stage, when treatment is most likely to work best. SERVICES NOT COVERED BY PART A OR PART B 
Acupuncture 
Chiropractic care, unless listed under covered services 
Cosmetic surgery 
Custodial care 
Dental 
Routine Eye care, unless listed under covered services 
Foot care, unless listed under covered services Benefit Facts Guide (Rev 8‐30‐11) 
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Hearing aides, exams and tests not ordered by a physician Lab screenings, unless listed under covered services Long‐term care Orthopedic shoes, unless listed under covered services Physical Exams, unless listed under covered services Prescription Drugs, unless listed under covered services or individual enrolled in Part D 44 | Page 
Immunizations, unless listed under covered services ENTITLEMENT PARTS A OR B A qualified beneficiary becomes entitled to Medicare for COBRA (Continuation of Coverage ‐ COC) purposes upon the effective date of enrollment in Medicare Part A or Part B, whichever occurs earlier. Qualifying Events: 
If a person is accessing Continuation of Coverage (COC) and becomes Medicare Eligible, COC will be terminated. 
If a person is actively at work and becomes Medicare entitled, actively at work benefits will be primary to Medicare Eligible Benefits. Upon retirement of active status for individuals 65 or older, Medicare will become primary to COC benefits. 
If a spouse is accessing coverage on spouse’s plan and spouse terms and both terminated employee and spouse access COC benefits and then spouse who terminated employment reaches Medicare age – Medicare will not be second qualifying event for Continuation of Coverage for non 65 year old spouse to continue on extended COC benefits. If non 65 year old spouse of a retiree then becomes disabled, Medicare will be primary. 
If a non 65 year old spouse of a 65 year old or older retiree becomes Medicare covered because of ESRD, the group plan remains primary for 30 months. ENTITLEMENT PART C 
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Medicare advantage Plans, sometimes called “Part C” or “MA Plans” are health plans offered by private companies approved by Medicare. If an individual joins a Medicare Advantage Plan, the plan provides all Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage plans always cover emergency and urgent care. Medicare Advantage Plans must cover all the services that Original Medicare covers, except hospice care. (Original Medicare covers hospice care even if the individual is in a Medicare Advantage Plan. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental and/or health and wellness programs. Most plans also include Medicare prescription drug coverage. Medicare Advantage Plans must follow rules set up by Medicare. However, each plan can charge different out‐of‐pocket costs and have different rules for how you to access services (such as a referral to see a specialist or network doctors, facilities, or suppliers that belong to the plan). Usually pay one monthly premium to the Medicare Advantage plan in addition to the Part B premium. Types of Medicare Advantage Plans include: Health Maintenance Organizations, Preferred Provider Organizations, Private Fee‐
for‐Service, Medical Savings Accounts and Special Needs Plan. MEDICARE PART D: VOLUNTARY PRESCRIPTION BENEFIT OPTIONS Benefit Deductible CoPay 2008 $275 See Aetna and CVS/Caremark SilverScript Plans 2009 $295 See Aetna and CVS/Caremark SilverScript Plans 2010 $310 See Aetna and CVS/Caremark SilverScript Plans Retail Mail Service See Aetna and CVS/Caremark SilverScript Plans See Aetna and CVS/Caremark SilverScript Plans See Aetna and CVS/Caremark SilverScript Plans Drug Spend Individual Spend $2,510 $4,050 ‐ Some plans have generic access in the gap $2,700 $4,350 $2,830 $4,550 $6,440 $6,447.50 $6,657.50 Greater amount of 5% or $2.25; Any other drugs $5.60 or 5% Greater amount of 5% or $2.40; Any other drugs $6.00 or 5% Greater amount of 5% or $2.50; Any other drugs $6.30 or 5% after drug spend of $6,447.50 Greater amount of 5% or $2.60, Any other drugs $6.50 or 5% after drug spend of $6,657.50 Total Covered Part D Drug Spending before Catastrophic Coverage Catastrophic Cost Benefit Facts Guide (Rev 8‐30‐11) 2011 $320 See UnitedHealthcare Group Prescription Solutions Plans See UnitedHealthcare Group Prescription Solutions Plans $2,930 $4,700 45 | Page MEDICARE PART D: DRUG COVERAGE 
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Everyone with Medicare eligible for Part D Drug plans are run by insurance or other private companies Each plan can vary in cost and drugs covered Late penalties are paid if individual does not enroll when first become eligible, (coverage in other creditable drug plans such as union or employer plans will allow penalties to be waived Can obtain coverage by joining either a Medicare Prescription Drug Plan, (PDP), or by joining a Medicare Advantage Plan, (MA‐
PD) Usually separate monthly premium for either type of plan Most plans will pay certain amount of money first, then a gap occurs where individual pays all out of pocket expenses to a certain amount. If limit of out of pocket expenses set by plan is reached, catastrophic coverage is implemented. If plan offered to cover the “gap” expenses this would be additional or more expenses premium. DEFINITION OF A PART D COVERED DRUG A Part D covered drug is a drug that is: 
Available only by prescription; 
Approved by the FDA (or is a drug described under section 1927(k)(2)(A)(ii) or (iii) of the Social Security Act); 
Used and sold in the United States; and 
Used for a medically accepted indication (as defined in section 1927(k)(6) of the Act). PART D EXCLUDED DRUGS The definition of a covered Part D drug excludes any drug for which, as prescribed and dispensed or administered to an individual, payments would be available under Parts A or B of Medicare for that individual, even though a deductible may apply. In addition, the definition of a covered Part D drug specifically excludes drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Medicaid under section 1927(d)(2) of the Act, with the exception of smoking cessation agents. The drugs or classes of drugs that may currently be otherwise restricted under Medicaid include the following: 
Agents when used for anorexia, weight loss, or weight gain, (unless for the treatment of AIDS wasting and cachexia); 
Agents when used to promote fertility; 
Drugs for erectile dysfunction unless they are to treat a condition other than sexual or erectile dysfunction and that condition has been approved by the FDA; 
Agents when used for cosmetic purposes or hair growth; 
Agents when used for the symptomatic relief of cough and colds; 
Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations; 
Nonprescription drugs; 
Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee as a condition of sale; 
Barbiturates; and 
Benzodiazepines. While these drugs or uses are excluded from basic Part D coverage, Medicare Part D drug plan sponsors can generally include them as part of supplemental benefits, provided they otherwise meet the definition of a Part D drug. MEDICARE PARTS B/D: DRUG COVERAGE COMPARISONS Coverage Category Covered Part Durable Medical Equipment (DME) Supply Drugs These are drugs that require administration by the use of a piece of covered DME (e.g., a nebulizer, or external or implantable pump). They are covered as a supply necessary for the DME to perform its function. The largest Medicare expenditures for drugs furnished as a DME supply are for inhalation drugs, which are administered in the home through the use of a nebulizer. The other category of drugs Medicare covers as a DME supply are drugs for which administration with an infusion pump in the home is medically necessary (e.g., some chemotherapeutic agents). Part B Benefit Facts Guide (Rev 8‐30‐11) 46 | Page Coverage Category Covered Part Supplies associated with the injection of insulin, including syringes, needles, alcohol swabs, gauze and insulin delivery devices not otherwise covered under Part B, such as insulin pens, pen supplies, needle free syringes, inhalation chamber and any future potential delivery mechanisms Part D Drugs furnished incident to a physician service Injectable or IV and not usually self administered Part B Immunosuppressant Drugs Part B for Medicare Covered Transplant Part D for all other indications Part B for cancer treatment Part D for all other indications Part B Oral Anti Cancer Drugs (if not usually self administered and provided incident to a physician’s service) Hemophilia clotting factors for hemophilia patients competent to use such factors to control bleeding without medical supervision, and items related to the administration of such factors. Oral Anti‐emetic Drugs Erythropoietin (EPO) and other ESRD treatment related drugs Part B for use w/in 48 hrs of chemo Part D for all other situations Part B for treatment of anemia for people undergoing dialysis Part D for all other situations Vaccines – Influenza, Pneumococcal, Hepatitis B (high risk patients) and associated administration fees Part B Parenteral Nutrition Antigens prepared by a physician, (usually an Allergist), and either administered in the office or self administered by the patient Intravenous Immune Globulin (IVIG) with diagnosis of immune deficiency disease. (IVIG only and administration of product not included) Drugs covered as supplies or “Integral to a Procedure – for example: radiopharmaceuticals, low osmolar contrast media, eye drops administered prior to cataract procedures Drugs furnished as a part of a service in Provider Settings – for example: drugs included under Out Patient Prospective Payment Systems, Comprehensive Outpatient Rehab Centers, Critical Access Hospital Out patient Departments, Rural Health Clinics, Federally Qualified Health Centers, Community Mental Health Centers, ESRD facilities, Ambulances and certain osteoporosis drugs in some Home Health Care settings Part D Hepatitis B for non high risk patients Part B is “permanent” dysfunction of digestive tract Part D for all other situations Part B Part B Part A/B Part A/B MEDIGAP OR MEDICARE SUPPLEMENTAL POLICIES 
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Designed to supplement out of pocket costs for services and supplies not paid for by original Medicare plans. Sold by private insurance companies, the benefits are very similar. May cover extra benefits not covered by Medicare. Cannot be purchased to cover code of co‐payments or deductibles for Medicare Advantage plans. Individuals must have Medicare Parts A and B. Medigap policies sold prior to 2006 are allowed to include drug coverage. There are no penalties for not having Part D coverage as long as the Medigap coverage is comparable or better to that of the Part D coverage. Benefit Facts Guide (Rev 8‐30‐11) 47 | Page THE MEDICARE PLAN FOR 2011 Medicare announce Medicare Premiums and Deductibles Part A Premium >40 quarters of Medicare covered employment 30‐39 quarters <39 quarters Part A (1‐60 day Deductible) (Inpatient hospital, skilled nursing, hospice, certain HHC services) 2010 $0.00 $244.00 $443.00 2011 $0.00 $248.00 $450.00 $1,100.00 $1,132.00 Approximately 99% of Medicare beneficiaries do not have to pay a premium for Part A services because they have at least 40 quarters of Medicare‐covered employment (or are the spouse or widow[er] of such a person). However, other seniors and certain people under age 65 with disabilities who have fewer than 30 quarters of coverage may obtain Part A coverage by paying a monthly premium set according to a statutory formula. Inpatient Charges 61‐90 days >90 days Beyond 150 days Skilled Nursing 21‐100 days Part B Premium $137.50/day $110.50 $283.00/day $566.00/day All costs for each day $141.50/day $115.40 $155.00 $162.00 $31.94 $32.34 $275.00/day $550.00/day (Physician, outpatient, certain HHC, DME and other services) Part B Deductible Part D Beneficiary Premium HIGHER PART B AND NOW PART D PREMIUMS FOR THE AFFLUENT Since 2007, as required in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, high‐income Medicare‐eligible individuals who enroll in the Part B program have been required to pay a monthly Part B premium that is higher than the standard premium. It varies depending upon enrollees' modified adjusted gross income and income tax filing status. The third column of the table below shows the 2011 Part B premium rates, all of which are just over 4% higher than in 2010. New in 2011 is an income‐related monthly adjustment for enrollees in Part D prescription drug plans. The Affordable Care Act requires Part D enrollees whose incomes exceed the thresholds established for Part B to pay their regular Part D premium to their plan (that amount will vary based on the plan they choose) and also pay an income‐related adjustment to Medicare. The last column of the following tables shows the 2011 income‐related monthly adjustment amount: Income Ranges by Tax Filing Status Individual Return* $85,001 to $107,000* Joint Return $170,001 to $214,000 Part B Premium Monthly Adjustment Amount for Part D Premium $161.50 $12.00 $107,001 to $160,000* $214,001 to $320,000 $230.70 $31.10 $160,001 to $214,000 $320,001 to $428,000 $299.90 $50.10 $214,000+ $428,001+ $369.10 $69.10 * Married beneficiaries with income in 2011 of more than $85,000 and less than or equal to $129,000 who file a separate return from their spouse and lived with their spouse at some time during the taxable year must pay the following monthly premium in 2011: $299.90. (The Part D monthly adjustment for these couples will be $50.10.) Married beneficiaries with income in 2011 of more than $129,000 who file a separate return from their spouse and lived with their spouse at some time during the taxable year must pay the following monthly premium in 2011: $369.10. (The Part D monthly adjustment for these couples will be $69.10.) For more information about Medicare prescription drug coverage: 
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Visit www.medicare.gov; Call your State Health Insurance Assistance Program; or Call 1‐800‐MEDICARE (1‐800‐633‐4227). TTY users should call 1‐877‐486‐0778 Benefit Facts Guide (Rev 8‐30‐11) 48 | Page PROVIDER NETWORK OVERVIEW TML IEBP Provider Network On October 1, 2006 TML IEBP changed the provider network to UnitedHealthCare Options PPO Network. The purpose of this change was to achieve more cost‐effective healthcare treatment. TML IEBP's Board of Trustees made the decision to enter into a long‐term agreement with United Medical Resources (UMR), a wholly owned subsidiary of UnitedHealthcare. The Alliance will promote comprehensive and cost‐efficient health benefit programs for political subdivisions in the State of Texas. The management support and systems flexibility provided by UMR will allow for UnitedHealthcare owned systems to manage the network and claims adjudication process efficiently. The Alliance network will be the UHN network in a majority of the counties in the State of Texas and will be accessed as the out of the State of Texas network. TML Intergovernmental Employee Benefits Pool will maintain some county and specific provider contracts to assist in minimizing unnecessary provider disruption. In addition, there are a few counties where TML Intergovernmental Employee Benefits Pool will maintain direct provider network relationship. To search the UnitedHealthCare Options PPO Network, please use the link below: www.provider.uhc.com/tml. For Out of State Provider Verification, please call 800‐651‐8231. •
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Direct Interface with Political Subd. Risk and Non‐Risk Claim Services Administrative Services Customer Services: Phone, Web, Patient Advocacy Prompt Pay Proactive Correspondence Plan Building Health Information Technology/Milliman Medical Management Underwriting Medication Therapy Management Program (MTMP) Reporting/Milliman Datawarehouse Billing and Eligibility/On‐Line System ID Card Internal Audits and Education Program Network Hierarchy Audit Legal/Legislative/Regulatory Support Website MBI/BPS Consumer Driven Debit Card Relationship Stop Loss Management Right of Recovery Services Support Services: Mail, Scan, Pre/Post Duplicate Audit Public Employees Benefit Alliance Services/Vendor Management Financial Integrity TML IEBP Business Continuity Plan Regulatory Compliance •
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TELA Data Entry Relationship D2 Hawkeye Relationship Validata audit of Eligibility Audit Repricing transmission to United Healthcare for claim repricing Using PPO One software SAS 70 Audit HealthX Relationship: Claim Look Up Claim Adjudication Platform iCES System Audit Service Claim Adjudication Service Team Marketing Synergy Claim Adjudication Business Continuity Support Health Information Technology UMR Business Continuity Security Guidelines TML IEBP Provider Direct Contract Repricing Provider/Member Appeals Options PPO Network • Three Tiered Secondary Network • TML IEBP Direct Contract Support • Premium Network Option • Repricing Software • System Audit/iCES • Provider Network Disruption Review • Provider Credentialing • TransReview Services for Transplant Case • Designated Bariatric Centers • Provider Network Website • Marketing Synergy Choice Plus Network • Three Tiered Secondary Network • Premium Network Options • Repricing Software • System Audit/iCES • Provider Network Disruption Review • Provider Credentialing • TransReview Services for Transplant Care • Designated Bariatric Centers • Provider Network Website • Marketing Synergy Benefit Facts Guide (Rev 8‐30‐11) 49 | Page What is a PPN? A Preferred Provider Network (PPN) plan contracts with select medical providers (e.g. physicians, hospitals, clinics, ancillary services, etc.) A panel of doctors reviews the providers’ credentials. PPN providers negotiate their fee schedules for covered employees and dependents. PPN providers are called network providers. Network providers cannot balance bill the covered employee or dependent for charges in excess of the negotiated fee schedule but may bill the covered employee or dependent for charges in excess of usual and reasonable. Advantages of a PPN Plan •
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The plan has a lower deductible that must be paid by the employee when a PPN provider is used. The plan pays a higher benefit percentage when a PPN provider is used. The covered employee or dependent may choose to access a Network or Non Network provider. How do I find a Provider? Finding Network Providers is the number one reason people come to the TML IEBP website. Follow these simple steps to find Network Providers: •
After logging in to myTML IEBP, click the “Provider Search” link found under the “Benefit Information” menu. •
Next, click on the type of search you would like to perform. Your options are Choice Provider, Choice Hospital or Other Facility, Medical Equipment or Supplies, Mental Health & Substance Abuse Provider or Facility, and Dental Provider or Facility. •
You may be directed to an external website to find the provider. If you are unable to find a network provider, contact TML IEBP’s Member Services department at (800) 282‐5385 for assistance. Choosing Your Doctors As with finding any professional, one good method is to ask friends, family members, and colleagues whether they can recommend someone. Keep in mind, that the doctor your grandmother loves may not be right for you. You may not need a doctor who specializes in elder care. The next best method is to consult your health plan’s network of participating doctors and medical professionals. You can find out about participating physicians’ specialties, board certifications and other details through information provided by your health plan. Making Your Choice You may have several candidates, all in your network and you cannot decide among them. Use your own criteria to narrow the field, but some common questions include the following: •
Affiliations: What hospital is the doctor affiliated with? Does the doctor belong to a medical group you can tap into if you need to? •
Appointments: How easily and quickly can you get an appointment? Can you get an appointment before or after your work hours or on Saturdays? •
Availability: Can you reach the doctor by phone or via e‐mail to answer questions? If you can’t talk to the doctor is there a nurse or physician’s assistant ready to help? •
Board Certification: Is the doctor board certified? Check www.abms.org or call toll‐free 866‐ASK‐ABMS to find out •
Satisfaction Ratings: Some health plans may offer members the opportunity to rate a health‐care provider based on their satisfaction level. These ratings are likely offered on the health plan’s Web site. •
Specialty: Does the doctor have expertise relevant to your needs? If you have young children, you may want a pediatrician or family physician. If your elderly mother is part of the family, you may want a physician with experience in geriatric care. Pay for Performance Networks Aligning incentives to determine what measures count, expanding scrutiny of the effectiveness of P4P, ensuring quality is the drive, no gains in terms of quality, standardization of measures and a continued increase in P4P programs, are among the expected actions and issues seen ahead for program s awarding incentives to physicians and hospitals for increasing quality and patient satisfaction according to results of the P4P Management Leadership Survey. Following is a list of the TML IEBP direct counties: Benefit Facts Guide (Rev 8‐30‐11) 50 | Page TML IEBP ACCESS TO UNITEDHEALTHCARE OPTIONS PPO TML IEBP Provider Direct Counties •
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Blanco Brown Gillespie Kendall Kerr Llano Taylor Val Verde Webb Employer Choice for East Texas Provider •
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ETMC Tyler and ETMC Rural Hospitals; or UnitedHealthCare Options PPO Network. Secondary Network Services •
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First Health (logo required) ‐ secondary network Multi‐Plan ‐ secondary network TC3 ‐ secondary network Ingenix ‐ professional negotiations Ethicare ‐ UCR TML IEBP Wrap Network In addition to the UnitedHealthCare Options PPO Network, TML IEBP Members have access to additional network providers through TML IEBP contracts. If you are unable to find a provider using the UnitedHealthcare provider directory you may search the TML IEBP Wrap Network. •
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Provider Request Form OPTIONS PPO TML IEBP SPECIALTY NETWORK Due to the need for specialty networks to improve the access to specialty providers and management of out of pocket and plan expenses, TML IEBP offers access to the Specialty Network options. The Specialty Network includes the following: Preferred Lab Benefit This Covered Individual is in a medical plan that utilizes preferred labs for outpatient services. The specimen can be collected at the physician’s office, or the test can be ordered and the Covered Individual sent to a preferred lab drawing site. If the specimen is drawn at your office, call one of the preferred labs in your area for specimen pickup. If the specimen is collected at the physician’s office, an administrative procedure may be billed. TML IEBP has added the Preferred Laboratories to the Provider Lookup section on the website. Now users can search for Preferred Labs in their area and print out a listing of their search results. Go online to the TML IEBP website (http://www.tmliebp.org/). •
Log in by entering your Username and Password. Select your Account Type and click “Log In”. •
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Next, click the “Provider Search” link found on the left navigation bar under Benefit Information. Benefit Facts Guide (Rev 8‐30‐11) 51 | Page •
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Next, click the “Preferred Labs” link. To narrow your search, enter a city, county or zip code. Click the “Search” button and you will see a list of Preferred Labs. Preferred Lab duplicate billing audits are conducted to identify providers who are billing erroneously for services rendered by the Preferred Lab and not the provider. Ineligible lab benefits will be billed to the Covered Individual. Major Imaging Services You can now take advantage of the new US Imaging VIP Appointment Scheduling Service when you need advanced imaging. After your doctor prescribes an advanced imaging test, such as an MRI, CT scan or PET scan, simply call TML IEBP (800) 847‐1213 per the notification requirements. US Imaging provides TML IEBP and their membership with improved discounted rates in addition to the following benefits: •
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VIP Appointment Scheduling within 24‐48 hours A fully credentialed network of facilities to ensure quality Access to after hours and weekend appointments Reminder calls with directions Follow up satisfaction call Designated Centers of Excellence •
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The Morbid Obesity treatment must be performed at a Plan‐Designated Morbid Obesity Treatment Center. The transplant must be performed at a hospital or facility designated by the Plan as a Transplant Center. A list of designated centers of excellence may be obtained from Medical Care Management. Notification Requirements Notification is required for the following admissions and/or procedures: SERVICE NOTIFICATION LATE NOTIFICATION PENALTY $200
Prior to appointment Radiology scheduling • Positron Emission Tomography (PET) scans • Computerized Axial Tomography (CAT) scans • Computerized Tomographic Angiography (CTA) scans • Magnetic Resonance Imaging (MRI) scans • Magnetic Resonance Angiography (MRA) scans Once the imaging services are approved, TML IEBP will contact the US Imaging VIP service and they will locate a credentialed, quality network facility to perform your test at a time and location that meets your needs. Once the US Imaging facility is located, the US imaging VIP Appointment Scheduling service will contact you to set up a convenient time for your appointment. In addition, when you access a US Imaging network facility you may greatly reduce your out‐
of‐pocket costs. TML IEBP ACCESS TO UNITEDHEALTHCARE CHOICE PLUS NETWORK Preferred Lab Benefit This Covered Individual is in a medical plan that utilizes preferred labs for outpatient services. The specimen can be collected at the physician’s office, or the test can be ordered and the Covered Individual sent to a preferred lab drawing site. If the specimen is drawn at your office, call one of the preferred labs in your area for specimen pickup. If the specimen is collected at the physician’s office, an administrative procedure may be billed. TML IEBP has added the Preferred Laboratories to the Provider Lookup section on the website. Now users can search for Preferred Labs in their area and print out a listing of their search results. Go online to the TML IEBP website (http://www.tmliebp.org/). •
Log in by entering your Username and Password. Select your Account Type and click “Log In”. •
Benefit Facts Guide (Rev 8‐30‐11) 52 | Page •
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Next, click the “Provider Search” link found on the left navigation bar under Benefit Information. Next, click the “Preferred Labs” link. To narrow your search, enter a city, county or zip code. Click the “Search” button and you will see a list of Preferred Labs. Preferred Lab duplicate billing audits are conducted to identify providers who are billing erroneously for services rendered by the Preferred Lab and not the provider. Ineligible lab benefits will be billed to the Covered Individual. Designated Centers of Excellence •
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The Morbid Obesity treatment must be performed at a Plan‐Designated Morbid Obesity Treatment Center. The transplant must be performed at a hospital or facility designated by the Plan as a Transplant Center. A list of designated centers of excellence may be obtained from Medical Care Management. OUT OF NETWORK PROVIDERS You can choose a provider that is not in the Options PPO network. If you choose to see a physician that is not in the network you will receive a reduced level of benefits and may need to submit requested paperwork. If your provider is not currently a member of the Options PPO network, TML IEBP encourages you to talk with the provider about submitting application. Please contact TML IEBP regarding the provider network application process or ask the provider to contact UnitedHealthCare Options PPO Network (877) 842‐3210. The UnitedHealthCare Options PPO Network phone number offers an automated approach to the application process. The provider will call the toll‐free number (877) 842‐3210; Chiropractors, Physical and Speech therapists should call (800) 873‐4575 ext 53413; Behavioral Health providers should go to www.ubhonline.com or call (800) 333‐8724. •
The provider will identify themselves by entering their Tax ID number on the phone keypad •
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The out of network provider will be required to submit an application, go through a fee negotiation and credentialing process, Out of Area What if I am on vacation and out of State? The PPN plan has physicians and facilities outside of Texas through the UnitedHealthCare Options PPO Network. To locate a PPN provider outside of Texas go to http://www.uhc.com/find_a_physician.htm for a list of PPN providers for that area. You may also call the customer service number found on your Medical/Prescription ID card. If a Covered Individual requires immediate care at a Non Network provider, the Plan will pay eligible benefits at the benefit percentage referenced on the Schedule of Medical Benefits subject to the Network deductible and Network out of pocket. Treatment or services provided outside the United States or its territories, unless required for immediate care, are excluded. Non‐Network Provider What if I use a provider who is not a member of the TML IEBP Alliance Options, Leased Network, and/or Direct Contract Providers PPN Network? Services provided by a Non Network provider are paid at the lower benefit percentage level and are subject to a separate calendar year deductible. Usual and Reasonable limits are utilized in determining maximum allowable charges. If the provider is billing in excess of the designated usual and reasonable limit, the covered employee or dependent will be responsible to pay the amount over the usual and reasonable amount. The employee will always be responsible for a portion of the bill. The Network and Non Network deductibles do not accumulate toward each other. Benefit Facts Guide (Rev 8‐30‐11) 53 | Page Emergency Care What if I need emergency care and the nearest hospital or doctor is out of network? The TML IEBP medical plan provides for emergency and immediate care situations. Eligible charges that are medically considered emergent or immediate care will be subject to the Network deductible and reimbursed at the network benefit percentage up to the usual and reasonable amount for the emergent pr or immediate eligible services. Important Disclaimer! The medical benefits are provided for eligible charges while you or your Dependent(s) are covered under this Plan. All services provided are subject to usual and reasonable charges and average wholesale pricing as determined by the Group Benefits Administrator. Authorization IS NOT a guarantee of payment under the plan. Payable benefits are subject to the terms and conditions of the health benefit plan. The benefits described are subject to all plan limitations, pre‐existing information, filing deadlines, exclusions and eligibility requirements. All benefits are based on Plan document language. If a Covered Individual is on continuation of coverage (COC), coverage could terminate retroactively if the individual's contribution is not made within the COC payment timeframe. If a Covered Individual is receiving care or about to receive care and is identified as not actively at work, continuation of coverage benefits may be offered, but must be accepted and paid per the continuation of coverage time guidelines for provider services to be considered for eligible benefit payment. Requests for reimbursement for a covered benefit should be sent to the Group Benefits Administrator within ninety (90) days of the date of service but not later than twelve (12) months. All inpatient and outpatient facilities are required to be JCAHO/Medicare accredited for the bill to be considered for payment. Benefit Facts Guide (Rev 8‐30‐11) 54 | Page NOTIFICATION REQUIREMENTS FOR OPTIONS PPO, CHOICE PLUS AND OUT OF NETWORK PROVIDERS Notification Requirements Notification enables clinical support and educations, such as: •
Perform pre‐op education for the patient and ensure adherence to nationally recognized guidelines in order to maximize quality and cost efficiency •
Facilitate post‐op discharge planning to optimize clinical outcomes •
Refer patients to Centers of Excellence Notification is required for the following admissions and/or procedures: SERVICE • INPATIENT ADMISSIONS NOTIFICATION LATE NOTIFICATION PENALTY Scheduled Specialty Admissions • Orthopedic/Spine Surgeries (spinal surgeries, total knee replacements, and total hip replacements) • Transplants: At least ten (10) working days prior to any pre‐
transplant evaluation, the covered individual or a family member must provide Notification to Medical Care Management; failure to do so will result in a Late Notification Penalty of $400 or a reduction in benefits • Reconstructive/Potentially Cosmetic procedures • Bariatric Surgeries: Morbid Obesity Services (after the approved six (6) month physician supervised weight management treatment plan) • Congenital Heart Disease Other Inpatient Admissions • Skilled Nursing Facility • Psychiatric/Chemical Dependency Inpatient • Psychiatric/Chemical Dependency Residential Treatment • Acute Care Hospital/Facility • Long Term Acute Care Facility • Acute Rehabilitation Facility • Scheduled Cesarean Section Delivery Facility: twenty‐four (24) hours after actual admission or by 5 pm the next business day for weekend/holiday admissions Facility: If admission Notification is not received within seventy‐two (72) hours of the admission, a 50% reduction will be applied to the contracted benefit eligible rate. Inpatient Pregnancy/Maternity (Delivery Admission) • Vaginal Delivery admission in excess of forty‐eight (48) hours • Cesarean delivery admission in excess of ninety‐six (96) hours • All High Risk obstetrical or antepartum care or other undelivered admission • Newborns who remain in the hospital after mother is discharged Pregnancy/Maternity • Sonogram/Ultrasound in excess of three (3) • Amniocentesis • Home Health (uterine monitoring) • Multiple birth diagnosis •
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Blepharoplasty (eyelid surgery) Breast Surgery Carpal Tunnel Release (nerve decompression) Jaw Surgery (including mandibular joint) Joint Surgery (excluding fingers & toes) Laparoscopy (except sterilization) Myringotomy or Myringoplasty (tympanic/ear drum surgery) Nasal Surgery Benefit Facts Guide (Rev 8‐30‐11) Primary Physician/Healthcare Professional: Prior to Admission Primary Physician/Healthcare Professional: If an advanced admission Notification is not received, a 100% reduction will be applied to the contracted benefit eligible rate. Facility: twenty‐four (24) hours after actual admission or by 5 pm the next business day for weekend/holiday admissions Facility: If admission Notification is not received within seventy‐two (72) hours of the admission, a 50% reduction will be applied to the contracted benefit eligible rate. Facility: twenty‐four (24) hours after actual admission or by 5 pm the next business day for weekend/holiday admissions Facility: If admission Notification is not received within seventy‐two (72) hours of the admission, a 50% reduction will be applied to the contracted benefit eligible rate. Prior to commencement for outpatient and Home Health procedures, within forty‐eight (48) hours of multiple birth diagnosis $200 Three (3) working days prior to procedure $200 55 | Page SERVICE • Tonsillectomy and/or Adenoidectomy • Uvulopalatoplasty (roof of mouth surgery) • Reconstructive Surgery • Cochlear Device and/or implantation • Artificial Intervertebral Disc Surgery • Stereotactic Radiosurgery • Bariatric Surgery (obesity surgery) •
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For Pain Management Chemotherapy NOTIFICATION LATE NOTIFICATION PENALTY Prior to commencement $200 •
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Psychiatric/Chemical Dependency Day Treatment Hospice Home Health Care Physician Home Visit Cardiac Rehabilitation Pulmonary Rehabilitation Positron Emission Tomography (PET) scans Computerized Axial Tomography (CAT) scans Computerized Tomographic Angiography (CTA) scans Magnetic Resonance Imaging (MRI) scans Magnetic Resonance Angiography (MRA) scans Single Photon Emission Computed Tomography (SPECT) Dental Injury (inpatient and outpatient) Dialysis for Kidney/Renal Failure Hyperbaric Oxygen Therapy Radiation Therapy Medically Necessary Evidence Based Genetic Testing Prior to commencement $200 •
Durable Medical Equipment For charges in excess of $1,000 prior to purchase, lease or rental $200 Responsibilities of Medical Care Management Medical Care Management does not confirm eligibility or benefits for any treatment or service. Upon Notification, Medical Care Management will provide the Covered Individual or Provider with contact information to enable the person to confirm eligibility and benefits with a Customer Service Representative. Benefit Facts Guide (Rev 8‐30‐11) 56 | Page PRIVACY OF YOUR HEALTH INFORMATION A Federal regulation, called the “Privacy Rule,” requires TML IEBP to protect the privacy of each covered individual’s identifiable health information. Under the Privacy Rule, TML IEBP may use and disclose a covered individual’s identifiable health information only for certain permitted purposes, such as the payment of claims under the health plan. If TML IEBP needs to use or disclose a covered individual’s health information for a purpose not permitted under the Privacy Rule, TML IEBP must first obtain a written authorization signed by the covered individual. In addition to restrictions on how TML IEBP may use and disclose a covered individual’s identifiable health information, the Privacy Rule gives each covered individual certain rights. These include the right of a covered individual to access his or her health information, to amend his or her health information and to receive an accounting of certain disclosures of his or her health information. TML IEBP’s Notice of Privacy Practices explains fully how TML IEBP may use and disclose a covered individual’s identifiable health information and a covered individual’s rights under the Privacy Rule. TML IEBP’s Notice of Privacy Practices is included with each covered individual’s enrollment information. TML IEBP’s Notice of Privacy Practices also is available on TML IEBP’s website at www.tmliebp.org, or an individual may request a paper copy of the notice by calling TML IEBP’s customer service number at (800) 282‐5385. SECURITY OF YOUR HEALTH INFORMATION A Federal regulation, called the “Security Rule”, requires TML IEBP to ensure the confidentiality, integrity and availability of a covered individual’s identifiable health information that TML IEBP receives, creates, maintains or transmits electronically. TML IEBP has implemented administrative, physical and technical safeguards that meet both Federal requirements and industry standards for the security of electronic health information. Benefit Facts Guide (Rev 8‐30‐11) 57 | Page DEFINITIONS Accountable Health Networks ~ proposed to provide high quality, lower‐cost care to patients (DRG, capitated contracting ‐ provider/payor sharing risk); PPACA bill promotes Medical Home Services to make primary care physician’s payment equitable to specialist providers 1.1.12‐still developing state waivers, anti‐kickback laws, self referrals. (65 measures must be met and over 5,000 beneficiaries must be served) Rule should be published 4.7.11 Alphanumeric HCPCS ~ stands for alphanumeric Health Care Financing Administration Procedure Coding System, HCPCS has three levels. 1. Level 1, CPT, is developed and maintained by the American Medical Association (AMA) and captures physician services; The “D” codes in the HCPCS system are dental codes created by the ADA and published as CDT. The ADA is the sole source of the authoritative version of CDT. 2. Level 2, alphanumeric HCPCS, contains codes for products, supplies and services not included in CPT. 3. Level 3, local codes, includes all the codes developed by insurers and agencies to fulfill local needs. HHS states local codes will be eliminated once regulatory compliance begins. Business Associate ~ means a person (not a member of a covered entity’s workforce) who helps a covered entity with a function or activity involving the use or disclosure of individually identifiable health information Capitation ~ In the strictest sense, a stipulated dollar amount established to cover the average cost of health care delivered for a person. The term usually refers to a negotiated per person rate to be paid periodically, usually monthly, to a health care provider. The provider is responsible for delivering or arranging for the delivery of all health services required by the covered person under the conditions of the provider contract. Carve Out ~ A decision to purchase separately a service which is typically a part of an indemnity or HMO plan. Example: an HMO may "carve out" the behavioral health benefit and select a specialized vendor to supply these services on a stand‐alone basis. Case Management ~ A process whereby members at the highest risk are identified and a plan which effectively utilizes health care resources is formulated and implemented to achieve optimum patient outcome in the most cost effective manner. Case Manager ~ An experienced professional (e.g., nurse, physician or social worker) who works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care. Case Mix ~ The relative frequency and intensity of hospital admissions or services reflecting different needs and uses of hospital resources. Case mix can be measured based on patients' diagnosis or the severity of their illnesses, the utilization of services and the characteristics of a hospital. CDS ~ Controlled dangerous substance CHIPS ~ Children’s Health Insurance Program Concurrent Review ~ An assessment which determines medical necessity or appropriateness of services are they are being rendered. Consumer‐Driven Health Care ~ An approach that encourages employees to take more control over their health care spending through such devices as a Health Reimbursement Arrangements (HRA) and/or Health savings accounts (H.S.A.) Continuation of Coverage ~ COBRA Consolidated Omnibus Budget Reconciliation Act of 1985. This law includes the federal mandate that requires employers to offer continuation health coverage to certain former employees and their covered spouses and dependents. Benefit Facts Guide (Rev 8‐30‐11) 58 | Page Continuum of Care ~ A range of clinical services provided to an individual which may reflect treatment rendered during a single inpatient hospitalization, or care for multiple conditions over a lifetime, or care across settings (acute‐‐skilled‐‐
home care‐‐self care). The continuum provides a basis for analyzing quality, cost and utilization over the long term. Cost Sharing ~ A general set of financing arrangements via deductibles, copays and/or coinsurance in which a person covered by the health plan must pay some of the cost of the care received. Covered Services ~ Those professional medical, hospital, and related services which (i) have been determined to be appropriate for the patient, AND (ii) are considered covered by the applicable benefits plan. Health benefit payors do not consider every available service a covered service. CPT ~ stands for Physician’s Current Procedural. CPT is used by physicians and other health care professionals to code their services for administrative transactions. CPT is level one of the Health Care Financing Administration Procedure Coding System (HCPCS). CPT codes are updated annually by the AMA. Credentialing Program ~ The goals, criteria, policies and procedures for credentialing physicians who desire to become or remain participating with a network or health plan. DEA ~ Drug Enforcement Agency Discharge Planning ~ The process, usually beginning upon admission which plans for the physical, social, emotional and medical needs of the patient upon discharge from an inpatient facility. Drug Formulary ~ A listing of prescription medications which are preferred for use by a health plan and which will be dispensed through participating pharmacies to covered persons. This list is subject to periodic review and modification by the health plan. A plan that has adopted an "Open or voluntary" formulary allows coverage for both formulary and non‐
formulary medications. A plan that has adopted a "closed, select or mandatory" formulary limits coverage to those drugs in the formulary. Emergency ~ The sudden and unexpected onset of an acute illness or accidental injury which is life threatening or likely to result in permanent disability if the patients fails to obtain medical treatment immediately or as soon as possible after the accident or injury. Employee Assistance Program ~ An employer maintained program that provides counseling and referral services for the treatment of drug abuse, alcoholism, emotional, mental and physical problems and financial or legal difficulties that can affect job performance. Encounter ~ A face‐to‐face meeting between a Member and a health care provider where services are provided. Encounter Form ~ The method of reporting services rendered to patients which are eligible for reimbursement. An encounter form is the same format as a HCFA1500 and UB92. Encounters per Member per Month ~ The number of encounters related to each Member on a monthly basis. The measurement is calculated as follows: Total # of encounters per month/total # of members per month. ERISA ~ Employee Retirement Income Security Act of 1974. Federal law that sets minimum standards for most voluntarily established pension and health plans in the private sector to protect plan participants. ERISA sets requirements for individuals and employers that administer, supervise or mange pension plan funds. Family Medical Leave ~ Family Medical Leave Act of 1993. Requires covered employers to allow eligible employees to take up to 12 weeks of unpaid leave in a 12‐month period for the birth or adoption of a child, or for a serious health condition of the employee or family member. FMLA applies to private employers with 50 or more employees for each working day of 20 or more weeks in the current or preceding calendar year, all public employers, and private elementary and secondary schools. Benefit Facts Guide (Rev 8‐30‐11) 59 | Page Fee for Service Equivalency ~ A quantitative measure of the difference between the amount a physician and/or other provider receives from an alternative reimbursement system (e.g., capitation) compared to fee‐for‐service reimbursement. Fee for Service Reimbursement ~ The traditional health care payment system, under which physicians and other providers receive a payment that does not exceed their billed charges for each unit of service provided. Fee Schedule ~ A listing of codes and related services with pre‐established payment amounts which could be percentage of billed charges, flat rates or maximum allowable amounts. FICA ~ Federal Insurance Contributions Act Formal Complaints ~ A patient problem presented for resolution which cannot be resolved immediately to the patient's satisfaction. Grievance ~ A written expression by a patient of a formal complaint which after being presented to the health plan has not been resolved to the patient's satisfaction and is presented for further investigation and resolution. Group Model ~ A health care model involving contracts with physicians organized as a partnership, professional corporation or other association. The health plan compensates the medical group for contracted services at a negotiated rate, and the group is responsible for compensation its physicians and contracting with hospitals for the care of their patients. HCFA 1500 ~ A universal form, developed by the government agency known as the Health Care Financing Administration (HCFA) for providers of service to bill professional fees to health carriers. HCFA Common Procedural Coding System (HCPCS) ~ A listing of services, procedures and supplies as ordered by physicians and other providers. The national codes are developed by HCFA in order to supplement CPT4 codes. They include physician services not included in CPT as well as non‐physician services such as ambulance, physical therapy, and durable medical equipment. The local codes are developed by Medicare carriers in order to supplement the national codes. HCPCS codes are five digit codes, the first digit a letter followed by four numbers. HCPCS codes beginning with A through V are national and those beginning with W through Z are local. Health Care Reform ~ Source: Time August 31, 2009 1.
Bending the curve: White House jargon for slowing the growth of health care spending which at current rates will exceed 20% of US gross domestic product by 2010 A.
Both parties agree that the rate of health care spending is unsustainable. A goal of most reform proposals is to bend, or lower, the growth curve to ease the burden on patients, employers, insurers and, most of all, the government, which relies on tax receipts to cover millions of seniors and poor people. 2.
Bundling: Giving the providers (i.e., doctors and hospitals) fixed bulk payments for taking care of patients rather than charging separately for each service or procedures A.
Health economists say bundling could lower overall health‐care spending by motivating doctors to focus on preventive medicine instead of encouraging them to perform unnecessary procedures. Some reform proposals would promote payment‐bundling. 3.
Defensive Medicine: Doctors and hospital often perform unnecessary tests and procedures on patients to ward of potential malpractice lawsuits. This drives up overall health‐care spending. Meanwhile, malpractice insurance can cost doctors hundreds of thousands of dollars per year A.
Many doctors admit they practice defensive medicine but say they have no choice because they are constantly worried about litigation. Tort reform—like capping malpractice awards could help, but it is not in any of the current proposals. Obama says he knows that defensive medicine is a problem, but he also knows that trial lawyers, who raised millions for him in 2008 oppose tort reform Benefit Facts Guide (Rev 8‐30‐11) 60 | Page B.
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Doughnut Hole: A gap in prescription drug coverage for Medicare recipients in Part D. Because of the way the law was written, some seniors have no coverage once their drug costs exceed $2,700* a year, until that have spent $4,350* out of own pocket. a.
*updated annually b.
Seniors who reach the doughnut hole often cut back on medications or stop taking them altogether, endangering their health. Obama recently made a deal with pharmaceutical companies that would cut the cost of brand name drugs 50% for seniors subject to the doughnut hole. C.
Guaranteed Issue: A proposed rule requiring health insurers to sell coverage to anyone who applies for it a.
All reform proposals would make this federal law, reversing the current insurance practice of turning away applicants who, for medical or other reasons, look like bad financial bets D.
Employer Mandate: A requirement that employers provide health insurance to workers or pay a financial penalty a.
Most employer mandate proposals would broaden workplace coverage but exempt some small businesses. E.
End of Life Care: Medical services for people who are in the last stages of life a.
More than a quarter of all Medicare funds are spent on people in their final year of life. One controversial reform proposal would reimburse doctors who counsel patients on end‐of‐life care, helping advise them on how to establish guidelines for the way they want to be cared for when they are dying. F.
Health Insurance Cooperative: A self‐insured pool of people some of whom could not otherwise afford insurance, who would collect premiums and pay out claims. These nonprofit co‐ops would be consumer owned and operated. a.
The Senate Finance Committee is eyeing the creation of co‐ops formed at the state or national level to help the uninsured and underinsured get quality coverage. Some policy experts think co‐ops would not be strong enough to pressure insurers to sufficiently lower rates and extend policies to cover the uninsured. Proponents believe co‐ops would provide competition to private insurers and operate independently of the government, pacifying critics of the public option. Individual Mandate: A requirement that every American buy health insurance, which would be enforced through financial penalties A.
An individual mandate is central tenet of some reform proposals because it is the mechanism for universal coverage, a vital step to lowering costs. Insurance companies back this provision in part because it would dramatically increase the number of Americans buying health insurance. Pooling: Grouping large numbers of people to spread out their health insurance risks. The larger and more diverse the Pool of people the cheaper their premiums can be. A.
Pooling would enable uninsured Americans and small firms that cannot afford insurance to link up in larger groups through a health‐insurance exchange regardless of pre‐existing conditions. Much of the backroom fighting in Washington is over whether these pools will be mandatory or voluntary, public or private, for profit or not‐for‐profit, government run or merely government regulated. Portability: The right to take your health insurance policy with you if you change or lose your job or if you move A.
Americans with employer sponsored health insurance lose their coverage if they leave their job. Although federal law guarantees that people with changed professional circumstances can sign up for new, individual policies, those policies tend to be prohibitively expensive. Most reform proposals would allow Americans who lose or change jobs to stay on their previous employer’s insurance. Public Option: A government‐run health insurance plan that could theoretically offer coverage at a price below that of private insurance plans. Federal leverage could lower administrative costs and reimbursements to doctors and hospitals. A.
Obama wanted a public option to keep the insurance companies honest by giving them competition. But he signaled he was willing to drop the ideal. This is a victory for private insurers, who strongly oppose a public option, and many Republicans who believe it would mean a massive federal intrusion in the free market. Benefit Facts Guide (Rev 8‐30‐11) 61 | Page 8.
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Rescission: Insurance companies practice of dropping patients after they file expensive claims, on the grounds that applicants misrepresented their medical history when they signed up for coverage. A.
Rescission has been the target of congressional hearings and would be banned by the reform proposals under consideration. In addition, insurers would no longer be permitted to restrict coverage or charge higher premiums for pre‐existing conditions. Single‐payer: A government‐run health care delivery system for all citizens, paid for by tax dollars. Both Britain and Canada have a single payer. A.
It doesn’t matter except in theory. No proposals under serious consideration call for a single‐payer plan. Conservatives who fear big government worry that more modest proposals are Trojan horse for a federal takeover of health care. Some liberals counter that a government‐run system is the fastest way to lower costs and extend coverage to all. Health Plan Employer Data and Information set (HEDIS) ~ A core set of performance measures to assist employers and other health purchasers in understanding the value of health care purchases and evaluating health plan performance. High Deductible Health Plan ~ A plan in which the annual deductible is at least $1,100 of individual coverage and at least $2,200 for family coverage, adjusted for inflation. Coverage under an HDHP is a requirement for creating a health savings account. (H.S.A.) Health Insurance and Portability Act ~ Under Federal laws known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Patient Protection and Affordable Care Act of 2010 (PPACA) and the Health Care and Education Reconciliation Act of 2010, group health plans, , generally must comply with the eligible benefit and security requirements. However, the law also permits State and local governmental employers that sponsor health plans to elect to exempt a plan from these requirements if that plan is self‐funded by the employer, rather than provided through a health insurance policy. HIPAA also will require HITECH compliance electronic healthcare transaction standardization from 4010 to 5010. This transition will impact the subscriber if separate ID numbers, Provider physical address, service type improvement Health Maintenance Organization ~ An organization that provides a range of health care services for a specific group of individuals for a fixed periodic fee. A legal entity consisting of participating medical providers that provide or arrange for care to be furnished to a given population group for a per‐person fixed fee. HMOs are used as alternatives to traditional indemnity plans as a way to mange costs and reduce health care expenses. Hybrid Entity ~ is a voluntary designation for a single covered entity that performs both covered and non‐covered functions. A covered entity may designate itself a hybrid entity to avoid imposition of the privacy rules on its non‐health care‐related functions. A hybrid entity must ensure that an entity’s health care component complies with applicable privacy provisions and the entity must have policies and procedures to ensure covered information is protected from inappropriate disclosure. In‐Area Services ~ Health care received within the authorized service area from a participating provider of care. Incurred But Not Reported (IBNR) ~ Costs associated with a medical service that has been provided, but for which a claim has yet to be received by the health plan. IBNR reserves are recorded by the carrier to account for estimated liability based on studies of prior lags in claims submissions. Integrated Delivery System ~ A generic term referring to a joint effort of physician/hospital integration for a variety of purposes. Some models of integration include physician hospital organization (PHO), management services organization (MSO), group practice without walls, integrated provide organization and medical foundation. International Classification of Diseases, 9th Edition (Clinical Modification) ICD‐9‐CM ~ A listing of diagnosis and identifying codes used by physicians for reporting diagnosis of health plan enrollees. The coding and terminology provide a uniform language that can accurately designate primary and secondary diagnosis and provide for reliable, consistent communication on claim forms. Benefit Facts Guide (Rev 8‐30‐11) 62 | Page International Classification of Diseases, 10th Edition (Clinical Modification) ICD‐10CM ~ Specificity and Manifestation ICD 9 transition to ICD 10. This will increase diagnosis specificity and allow manifestation to be identified. Clinical quality and coordinated care: 5X more diagnosis codes 69,000 (3‐7 characters), 20x more injury codes, 15x more AMA professional procedure code(7 digits) 71,000 codes; Independent Medical Evaluation (IME) ~ An examination carried out by an impartial health care provider generally board certified, for the purpose of resolving a dispute related to the nature and extent of an injury or illness. Independent Practice Association (IPA) ~ A health care model that contracts with an entity, which in turn contracts with physicians, to provide health care services in return for a negotiated fee. Physicians continue in their existing individual or group practices and are compensated on a per capita, fee schedule or fee for service basis. Independent Review Organization ~ Medical Plan external review 0rganization to verify accuracy of benefit plan and clinical review adjudication process JCAHO ~ The Joint Commission on Accreditation of Healthcare Organizations. Length of Stay ~ The number of days that a patient stayed in an inpatient facility. Mandated Providers ~ Providers of medical care, such as psychologists, optometrists, podiatrists and chiropractors whose licensed services must under a State law or Federal law be included for coverage offered by a health plan. Medical Loss Ratio ~ The cost of health benefits used, compared to revenue received. Medically Necessary ~ Those medical treatments, supplies or services ordered by a physician to treat a patient's sickness, bodily injury or complication of pregnancy or pregnancy that are: 1.
Consistent with symptoms, or diagnosis and treatment of the condition, disease, ailment or injury; and 2.
Appropriate with regard to standards of good medical practice prevailing in the community where treatment occurs at the time such treatment is required; and 3.
Not primarily for the convenience of the patient, patient's family or the treating physician. Member Month ~ A count which records one Member for each month the Member is effective. Network ~ An organization consisting of physicians and/or hospitals and/or ancillary providers formed through contractual relationships. NCQA ~ The National Committee for Quality Assurance. NCQA is the accrediting body for managed care organizations with processes for auditing and reviewing similar to JCAHO. NDC ~ stands for National Drug Codes. NCS are used in reporting prescription drugs in retail pharmacy transactions, but, in February 2003, HHS eliminated the requirement for their use in other transactions. The 11‐digit codes are assigned when the drugs are approved or repackaged and may be found on the packaging of drugs. The codes are established by the Food and Drug Administration. Non‐Covered Services ~ Those health care services that are not listed under the applicable benefit plan. Non‐Participating (Non‐Par) Provider ~ A term used to describe a provider of care that has not contracted with the health benefits carrier or a participating network. NPDB ~ National Practitioner Databank which is a Federal entity that was established in 1986 to collect and release certain information relating to the professional competence and conduct of physicians, dentists, and other health care professionals. Open Access ~ A self‐referral arrangement allowing Members to see participating providers of care without a referral from a Primary Care Physician. Typically found in IPA HMO. Also called open pan, self‐referral programs. Benefit Facts Guide (Rev 8‐30‐11) 63 | Page Outcome Measures ~ Assessments which gauge the effect or result of treatment for a particular disease or condition. Outcome measures include the patient's perception of restoration of function, quality of life, and functional status, as well as objective measures of mortality, morbidity and health status. Outcomes Research ~ Studies aimed at measuring the effect of a given product, procedure or medical technology on health or costs. Outlier ~ An observation in a distribution that is outside a certain range, often defined as two or three standard deviations from the mean or exceeding a specific percentile. Frequently refers to a case of hospital stay that is unusually long or expensive for its type, or to a physician practice that uses an abnormally high or low volume of resources. Out of Area ~ Coverage for treatment obtained by a covered person outside of the network service area. Out of Pocket Expenses ~ The portion of payments for health services required to be paid by the enrollee, including copayments, coinsurance and deductibles. Patient Protection and Affordable Care Act of 2010 (PPACA) ~ Is a federal statute that was signed into United States law by President Barack Obama on March 23, 2010. This Act and the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010) made up the health care reform of 2010. The laws focus on reform of the private health insurance market, provide better coverage for those with pre‐existing conditions, improve prescription drug coverage in Medicare and extend the life of the Medicare Trust fund by at least 12 years.[3] The PPACA passed the Senate on December 24, 2009, by a filibuster‐proof vote of 60–39 with all Democrats and Independents voting for, and all Republicans voting against. It passed the House of Representatives on March 21, 2010, by a vote of 219–212, with 178 Republicans and 34 Democrats voting against the bill. The law has received legal challenges regarding its constitutionality. Three cases in federal courts upheld the constitutionality of the bill while two deemed it unconstitutional.[4] Six other challenges were dismissed on grounds such as plaintiffs being unable to demonstrate sufficient standing.[4] The Supreme Court could review this law as early as the end of 2011 or the beginning of 2012. Paid Claims ~ The amounts paid to providers to satisfy the contractual liability of the carrier or plan sponsor. These amounts do not include any covered persons liability for ineligible charges or for deductibles or copayments. Partial Hospitalization Services ~ A mental health or substance abuse program operated by a hospital which provides clinical services as an alternative or follow‐up to inpatient hospital care. Payor ~ The purchaser of covered services which may include claims administrators, employers, insurance carriers, third party employee benefit plan administrators, self‐funded plans and groups, and other similar arrangements. Peer Review Organization (PRO) ~ An entity established by the Tax Equity and Fiscal Responsibilities Act of 1982 (TEFRA) to review quality of care and appropriateness of admissions, re‐admissions, and discharges for Medicare and Medicaid. These organizations are held responsible for maintaining and lowering admission rates, and reducing lengths of stay while insuring against inadequate treatment. Also known as professional standards review organizations. Physician Hospital Organization (PHO) ~ A legal entity formed and owned by one or more hospitals and physician groups in order to obtain payor contracts and to further mutual interests. Physicians maintain ownership of their practices while agreeing to accept managed care patients under the terms of the PHO agreement. The PHO serves as a negotiating, contracting and marketing unit. Point of Service (POS) ~ A health plan allowing the covered person the opportunity to choose to receive a service from a participating or a non‐participating provider, with different benefit levels associated with the use of participating providers. Point of service can be provided in several ways: 1.
An HMO may allow Member to obtain services from non‐participating providers; 2.
An HMO may provide non‐participating benefits through a supplemental plan; 3.
A PPO may be used to provide both participating and non‐participating levels of coverage/access; or 4.
Various combinations of the above. Benefit Facts Guide (Rev 8‐30‐11) 64 | Page Pool ~ A defined account (e.g. defined by size, geographic location, claim dollars that exceed X level per individual, etc) to which revenue and expenses are posted. A risk pool attempts to define expected claims liabilities of a given defined account as well as required funding to support the claim liability. Practice Guidelines ~ Systematically developed standards on medical practice that assist a practitioner and a patient in making decisions about appropriate health care for specific medical conditions. Preferred Provider Organization (PPO) ~ A program in which contracts are established with providers of medical care. Providers under such contracts are referred to as preferred providers. Usually, the benefit contract provides significantly better benefits (lower out of pocket responsibility) for services received from preferred providers, thus encouraging covered persons to use these providers. Covered persons are generally allowed benefits for non‐participating providers' services, usually on an indemnity basis with significant copayments. A PPO arrangement can be insured or self‐funded. Providers may be, but are not necessarily, paid on a discounted fee for services basis. Prior Authorization ~ The process whereby a health plan reviews the recommended plan of treatment to pre‐established criteria to determine medically necessity criteria to determine if the service will be a covered benefit or not. The review is done prior to the services being provided. Providers of care are responsible for obtaining the review and providing the necessary information. Quality Assurance (Improvement) ~ A formal set of activities to review and affect the quality of services provided. Quality assurance includes quality assessment and corrective actions to remedy any deficiencies in the quality or direct patient, administrative and support services. Quality Improvement Program ~ The program established by a health plan at least annually to gather and analyze the performance data specific to care received by Members and/or provided by participating providers. Referral Access ~ A type of health plan in which covered persons are required to select a PCP from the plan's participating listing. The patient is required to see the selected PCP for care and referrals to other health care providers within the plan. These types of health plans are typically found in the staff, group or network model POS. Also called closed access, closed pane, coordinator or gatekeeper model. Reserves ~ Funds for incurred but not reported health services or other financial liabilities. Also refers to deposits and/or other financial requirements that must be met by an entity as defined by various state or federal regulatory agencies. Resource Based Relative Value Scale (RBRVS) ~ A fee schedule introduced by HCFA to reimburse physicians' Medicare fees based on the amount of time and resources expended in treating patients, with adjustments for overhead costs and geographical differences. Retention ~ That portion of the cost of a medical benefit program which is kept by the health plan to cover internal costs or to return a profit. Retrospective Review ~ A determination of medical appropriateness and/or appropriate billing practices for services already rendered. Service Area ~ The geographic area serviced by the health plan as approved by State regulatory agencies and/or as detailed in the certification of authority (state approval to do business document). Standard Benefit Package ~ A set of specific health care benefits that would be offered by delivery systems. Benefit packages could include all or some of the following: preventive care services, hospital and physician services, prescription drug coverage, limited mental health and chemical dependency services and/or long‐term care. Third Party Administrator ~ A company that accepts responsibility for administering some or all of an employer’s benefits programs. Trending ~ A calculation used to predict future utilization of a group based on past utilization by applying a trend factor. Benefit Facts Guide (Rev 8‐30‐11) 65 | Page Unbundling ~ Separately packaging units that might otherwise be packaged together. For claims processing, this includes providers billing separately for health care services that should be combined according to industry standards or commonly accepting coding practices. Also refers to the practice of providing separate prices and administrative support for services such as prescription drug benefit administration, mental health/substance abuse services or utilization review services. Uniformed Services Employment and Reemployment Rights Act ~ USERRA ensures that employees who leave their jobs to serve in the military will not lose benefits, including 401(k) plan contributions, when they return to work. Voluntary Employees’ Beneficiary Association ~ A trust tax‐exempt under Code Section 501c (9) that is created to fund life insurance, sick leave, accident or certain other benefits for a nondiscriminatory class of employees, their dependents or designated beneficiaries. United Health •
Optum (Wellness Service) •
UMR (United Medical Resources) •
Options PPO (National Network) •
URN (United Transplant Network) •
United Resource Network (Transplant Network) •
ACN Group (Ancillary Network) •
United Behavioral Health‐Employee Assistance Program •
Spectera (Vision) •
NBR (Stop Loss) •
Unimerica (Life and Disability) •
Exante (Financial Services and Exante Bank awaiting regulatory approval in 2008) Renamed OptumHealth Financial Services •
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Diabetes: http://www.diabetes.org/advocacy‐and‐legalresources/cost‐of‐diabetes.jsp National Breast and Cervical Cancer: http://www.cdc.gov/cancer/nbccedp Prostate Conditions Education Council (PCEC): http://www.prostateconditoins.org/programs_and_events Screenings from American Cancer Society: http://www.cancer.org Planned Parenthood: http://www.plannedparenthood.org Health Fairs Low‐cost Screenings: http://www.covertheuninsured.org Health Human Service Office of Inspector General HHSTips: http://www.oig.hhs.gov State Health Insurance Assistance Program: http://www.tdi.state.tx.us/consumer/hicap/hicaphme.html Medicare: 1.800.633.4227 Social Security: 1.800.772.1213 Medicare Coordination of Benefit Contractor: 1.800.999.1118 Department of Defense/Tricare: 1.866.773.0404 Department of Health and Human Services Office of Inspector General: 1.800.447.8477 Office for Civil Rights: 1.800.368.1019 Department of Veterans Affairs: 1.800.827.1000 Medicaid: Call 1.800.633.4227 and say “Medicaid” to get the telephone number for your State Medical Assistance (Medicaid) office Medicare Drug Integrity Contractor: 1.877.722.3379 Benefit Facts Guide (Rev 8‐30‐11) 66 | Page Healthcare links not found on TML IEBP Website as of 5/2/11 •
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National Institute of Health: http://health.nih.gov/ Centers for Disease Control and Prevention: http://www.cdc.gov/ Women’s Health: http://www.womenshealth.gov/ National Cancer Institute at National Institutes of Health: http://www.cancer.gov/ National Institute of Aging: http://www.nia.nih.gov/ National Guideline Clearinghouse: http://www.guideline.gov/ President’s Council on Fitness, Sports, and Nutrition: http://www.fitness.gov/ Health finder.gov: http://www.healthfinder.gov/ Consumer Health Information in Many Languages Resources: http://nnlm.gov/outreach/consumer/multi.html Agency for Healthcare Research and Quality: http://www.ahrq.gov/ Benefit Facts Guide (Rev 8‐30‐11) 67 | Page