2012 NRECA Medical Plan (High Deductible PPO

Transcription

NRECA Medical Plan
___________________________________________________________________________
SUMMARY PLAN DESCRIPTION
High Deductible PPO Plan
For:
SEMO ELECTRIC COOPERATIVE
01-26031-003
EFFECTIVE DATE: January 1, 2012
Introduction
This document is a Summary Plan Description (SPD) providing you with a summary of the key
provisions of the NRECA Medical High Deductible PPO Plan (referred to as the “Plan” in this
document) for SEMO ELECTRIC COOPERATIVE. This Plan is a component plan of the
NRECA Group Benefits Program. In the pages that follow, you will find information on the
benefits provided by the Plan.
If you are eligible to participate in the Plan, you may choose coverage for yourself and any eligible
dependents.
Each participant in this Plan is responsible for reading this SPD and related materials completely
and complying with all rules and Plan provisions.
While the Plan’s provisions determine what services and supplies are eligible for benefits, you and
your health care provider have ultimate responsibility for determining appropriate treatment and
care.
If the terms of this SPD conflict with the terms of the governing plan document, then the terms of
the governing plan document will control, rather than this SPD.
Table of Contents
Chapter 1:
Contacts...................................................................................................................................... 5
Chapter 2:
High Deductible PPO Plan Highlights .................................................................................. 6
Medical Benefit Highlights ...................................................................................................... 6
Prescription Drug Benefit Highlights .................................................................................... 7
Plan’s Deductible and Annual Out-of-Pocket Coinsurance Maximum Highlights ........ 7
Chapter 3:
Eligibility and Participation Information ............................................................................... 8
Coverage for Your Dependents ............................................................................................. 8
You and Your Spouse or Child Work for Co-ops ............................................................... 9
Eligibility Waiting Period ......................................................................................................... 9
When Coverage Begins (Participation Date) ......................................................................10
Cost of Coverage ....................................................................................................................10
Making Changes During the Year and Special Enrollment ..............................................10
When Coverage Ends.............................................................................................................12
Chapter 4:
Medical Benefits ......................................................................................................................13
How the Plan Works ..............................................................................................................13
What the Plan Covers.............................................................................................................15
Medical Services Covered Under the Plan ..........................................................................17
Clinical Policy Bulletins ..........................................................................................................36
Coverage While Traveling Outside the United States .......................................................37
WebMD Health Manager ......................................................................................................38
MyHealth Coaches..................................................................................................................38
Charges Excluded Under the Plan .......................................................................................39
General Exclusions .................................................................................................................41
Coordinating Benefits with Other Plans .............................................................................41
Chapter 5:
Medical Claims and Appeals .................................................................................................43
Claims and Appeals Procedures ...........................................................................................43
Internal Process for Medical Claims and Appeals .............................................................44
External Review Process for Claims Denials and Coverage Rescissions .......................48
Expedited External Review Process ....................................................................................50
Chapter 6:
Prescription Drug Benefits ....................................................................................................51
How the Plan Works ..............................................................................................................51
What the Plan Covers.............................................................................................................53
Prescription Drug Support Online .......................................................................................57
Pharmacy Clinical Support ....................................................................................................58
Drug and Supplies Excluded Under the Plan .....................................................................58
Coverage Under Medicare .....................................................................................................59
Coordination of Benefits .......................................................................................................60
Chapter 7:
Prescription Drug Claims and Appeals ...............................................................................60
Claims and Appeals Procedures ...........................................................................................60
Internal Process for Filing Prescription Drugs Appeals ...................................................61
Chapter 8:
Mental Health and Substance Abuse Benefits ....................................................................64
Life Strategy Program.............................................................................................................65
Chapter 9:
Plan Information .....................................................................................................................66
Chapter 10: Administrative Information...................................................................................................68
Not a Contract of Employment ...........................................................................................68
Non-Assignment of Benefits ................................................................................................68
Third Party Liability................................................................................................................68
Mistakes in Payment ...............................................................................................................68
Right of Recovery of Overpayment .....................................................................................69
Changing or Terminating the Plan .......................................................................................69
Severability ...............................................................................................................................69
Chapter 11: Federal Laws Impacting This Plan .......................................................................................69
Women’s Health and Cancer Rights Act (WHCRA) ........................................................69
Statement of ERISA Rights ..................................................................................................69
HIPAA Privacy Rights ...........................................................................................................71
Family and Medical Leave Act (FMLA) ..............................................................................71
USERRA (Benefits While on Military Leave) ....................................................................72
COBRA Continuation Coverage ..........................................................................................72
Chapter 12: Definitions ...............................................................................................................................79
Chapter 1:
Contacts
Information about:
•
Review of
Hospital
Admissions
• Precertification
of Hospital
Admissions
• First Steps
Maternity
Program
• Medical Case
Management
• Discharge
Planning
Information about:
•
•
•
Claims
Clinical Policy
Bulletins
General Plan
Questions
Information about:
•
Prescription
drug benefits
Information about:
•
•
•
•
•
•
•
Eligibility
Enrollment
When Coverage
Begins or Ends
Cost of Coverage
COBRA
FMLA
General
Questions
Simplified Hospital Admissions Review (SHARE)
Medical Review Coordinators
1-800-526-7322
(8am to 7pm EST Monday-Friday)
Claims Administrator
Cooperative Benefit Administrators, Inc. (CBA)
P.O. Box 6249
Lincoln, NE 68506
1-866-673-2299, press # 1
https://benefits.cooperative.com/app/ElectronicEob/ClaimsInformat
ion
Customer Service
CVS Caremark, Inc.
P.O. Box 686005
San Antonio, TX 78268-6005
1-888-796-7322 or [email protected]
(24-hour customer care)
www.caremark.com
Benefits Administrator
P.O. BOX 520
SIKESTON, MO 63801
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Chapter 2:
High Deductible PPO Plan Highlights
This Chapter includes the highlights of your benefits under the Plan. For further information
about these benefits, other benefits, limitations, and Plan exclusions – please read Chapters 4 and
6.
Medical Benefit Highlights
MEDICAL BENEFIT: PLAN PAYS
SERVICE:
IN-NETWORK*:
PLAN PAYS
OUT-OF-NETWORK*:
Preventive Care for
Adults
100%
60%
Well-Child Care
100%
60%
Physician Benefits
(includes benefits for
Mental Health and
Substance Related
Disorder treatments)
80% after deductible
Diagnostic
services
Preventive
tests and
screenings
100%
60%
LabCard
Select
N/A
N/A
Hospital (includes
benefits for Mental
Health and Substance
Related Disorder
treatments)
Emergency Room
(includes benefits for
Mental Health and
Substance related
disorder treatments)
Convalescent Nursing
Home Care
Hospice Care
Other Medical Services
Diagnostic
Lab & XRay
*Keep in mind: May be subject to the annual out-of-pocket coinsurance maximum, R&C Rates,
and other service maximums and/or benefit maximums.
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Prescription Drug Benefit Highlights
Important Note: If you are a retiree, you and your dependents for whom Medicare is the
primary insurer are NOT eligible to participate in the Prescription Drug Benefit under
the Plan. Please read “Coverage Under Medicare” in Chapter 6.
PRESCRIPTION PLAN PAYS IN-NETWORK*:
DRUG BENEFIT:
PLAN PAYS OUT-OF
NETWORK:
Generic and Brand
Name Drugs
Retail Pharmacy
(30-day supply)
80% of the cost of the drug**
60% of the cost of the drug
minus the difference between
the drug’s actual cost and the
cost if the drug had been
obtained In-Network
Mail Service
Pharmacy
80% of the cost of the drug**
N/A
(90 day supply)
* In-Network refers to any Retail Network Pharmacies. To find a Retail Network Pharmacy
contact CVS Caremark (see “Chapter 1”).
**Subject to the annual deductible and annual out-of-pocket coinsurance maximum.
Plan’s Deductible and Annual Out-of-Pocket Coinsurance Maximum
Highlights
the Plan. Please read “Coverage Under Medicare” in Chapter 6. Further, as a retiree
with Medicare primary insurance, your prescription drug expenses fall outside of the
Plan and do not count towards the Plan’s deductible or annual out-of-pocket
coinsurance maximum.
For more information about the Plan’s deductible and annual out-of-pocket coinsurance
maximum see Chapter 4.
Deductible
Your annual deductible (combined for medical expenses and prescription drug expenses):
DEDUCTIBLE: IN-NETWORK*:
OUT-OF-NETWORK*:
Individual
$1,200
$1,200
Family
$2,400
$2,400
* Amounts that count toward satisfying an in-network deductible also count toward satisfying an
out-of-network deductible and vice versa.
Keep in mind: Under this Plan, covered services are not reimbursed for any family (you
and your dependents) member until the family deductible noted above is met.
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Annual Out-of-Pocket Coinsurance Maximum
Your annual out-of-pocket coinsurance maximum (combined annual maximum for out-ofpocket medical expenses and prescription drug out-of-pocket expenses):
ANNUAL OUT-OF-POCKET
COINSURANCE MAXIMUM:
IN-NETWORK:
OUT-OF-NETWORK:
Individual
$1,500
$3,000
Family
$3,000
$6,000
Chapter 3:
Eligibility and Participation Information
The following employee classifications are eligible for participation in the Plan:
• Active Employees
• Dependents of Employees
• Disabled Employees receiving employer-sponsored LTD benefits
• Dependents of Disabled Employees receiving employer-sponsored LTD benefit
• Retired Employees (if covered by the Plan before they retire)
• Dependents of Retired Employees
Your employer treats employees who are out on long-term disability (as defined by your
employer’s long-term disability plan) as active employees for purposes of eligibility to participate
in this Plan.
For purposes of coverage under the Plan, your Employer defines “Retiree” as a former employee
who has met the following criteria:
A person who retires at or after age 55, regardless of years of service
The following job classifications of employees are not eligible for participation in this Plan:
This Plan does not have any excluded job classifications, positions or titles.
If you have any questions regarding eligibility, please see your Benefits Administrator.
Other Eligibility Requirements
In addition to meeting the eligibility requirements noted above, you must also:
•
Be expected to work at least 1,000 hours as an active employee during your first 12
months of employment;
•
Have worked at least 1,000 hours during each subsequent calendar year; or
•
Have worked at another co-op within the past six months and met the other criteria
above.
Coverage for Your Dependents
Your dependents are eligible to participate in the Plan if you meet the requirements of
participation, as noted above, and if they are:
•
Your legal spouse;
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•
Your unmarried and/or married children, up to age 26 who are your biological, adopted
children, stepchildren, or children for whom you have proof of legal guardianship, upon
request. If you have adopted children, children placed for adoption, stepchildren or
children for whom you have legal guardianship, you must provide any substantiating
documentation required by the Plan, upon request;
•
Your children who are recognized under a qualified medical child support order
(QMCSO) as having a right to enrollment under your group health plan may be covered
under the Plan if the children are otherwise eligible; and
•
Not serving in the military.
Coverage for your child will end as of midnight on the last day the covered child is 25 years of
age.
Please keep in mind: The Plan may request substantiating eligibility documentation, upon
request. In the event your dependent(s) are later found to be ineligible for coverage, coverage
will be cancelled retroactively to the effective date of coverage and the Plan will seek to recover
any claims paid on the ineligible dependents’ behalf.
Incapacitated Adult Child Requirements
An incapacitated adult child over age 25 is eligible for coverage under the Plan if:
1. the child was enrolled in the Plan before the date eligibility would have ended due to age,
2. the child is unmarried,
3. the child is mentally or physically unable to earn his or her own living,
4. proof of incapacity is furnished to NRECA within 31 days of the date the child’s
eligibility would have ended due to age (ongoing proof is required on a periodic basis),
and
5. the child relies on the employee for greater than 50% of the child’s support.
If you are a newly hired employee with an incapacitated adult child who is over age 25, your
incapacitated child is eligible for coverage under the Plan if he or she was covered by your
previous insurer prior to becoming an over-age dependent and satisfies the requirements
specified in items 2, 3, 4, and 5 noted above. In addition, documentation of the previous
coverage will be requested at the time you request coverage for your incapacitated child.
Please consult your personal tax advisor regarding the potential tax consequences of covering
your child who does not qualify as a dependent for purposes of tax-free employer-sponsored
coverage.
You and Your Spouse or Child Work for Co-ops
If both you and your spouse or child work for an NRECA member cooperative and are eligible
for coverage separately, both of you will be covered as employees unless you also wish to cover
dependents. If you wish to cover dependents, either you or your spouse (or child) will be
covered as an employee, and the other will be covered as a dependent. If the employed
dependent is a child, then the child will be covered either as a dependent or as an employee. In
no case can someone be covered under the Plan as both an employee and as a dependent.
Eligibility Waiting Period
In order to be eligible to participate in the Plan, you must have satisfied your employer’s
eligibility waiting period and have completed and returned the NRECA Employee Worksheet to
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your Benefits Administrator within 31 days of satisfying your employer’s eligibility waiting
period.
The eligibility waiting period is the length of time that you must have worked for your employer
before you can participate in the Plan.
Your Plan has the following eligibility waiting period:
An active employee is eligible to participate in the Plan after: 1 Month
If directors or a retained attorney are eligible for this Plan and do not share in the cost of their
coverage, they do not need to satisfy a waiting period, and coverage begins on the date that the
director’s term commences. If directors share in the cost of their coverage, they are required to
complete an NRECA Employee Worksheet, and coverage commences on the date that the
enrollment worksheet is signed.
When Coverage Begins (Participation Date)
You are covered under this Plan effective on the later of: the effective date of the Plan, or the
date you meet the eligibility criteria (see “Eligibility for Participation” and “Eligibility Waiting
Period” sections.)
Cost of Coverage
You and your employer share in the cost of your coverage and your eligible dependent’s
coverage, if applicable, as follows:
•
Active Employees: You and the Employer share in the cost of the coverage. [Per active
union contract]
• Dependents of Employees: You and the employer share in the cost of the coverage.
• Disabled Employees: You and the employer share in the cost of the coverage. [Per
active union contract]
• Dependents of Disabled Employees: You and the employer share in the cost of the
coverage.
• Retired Employees: You pay the entire cost of your coverage. [Per active union
contract]
• Dependents of Retired Employees: You pay the entire cost of your coverage.
Specific information regarding the cost of your coverage will be provided to you before you
enroll in the Plan, whether such enrollment is your initial enrollment, annual enrollment, or
special enrollment. The cost of this coverage is subject to your employer’s policies and can
change at any time.
Making Changes During the Year and Special Enrollment
If you decline coverage during your initial enrollment period, you may qualify to add or drop
coverage for yourself and your eligible dependents, as applicable, if you experience the following
events:
•
Marriage, birth, adoption, placement of adoption, or legal guardianship if you enroll
within 31 days after the event and the new dependents meet the requirements for
eligibility.
•
Divorce or death of spouse or dependent child, if you enroll within 31 days after the
event date.
•
Eligible dependent children may also add or drop coverage within 31 days of their loss or
gain of other group health plan coverage (see “Losing Other Coverage” below).
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•
Changes in employment status that would make you eligible to participate in the Plan.
•
Annual enrollment, if offered by your Employer.
Coverage will become effective retroactively to the date of the divorce, marriage, birth, adoption,
placement for adoption, or legal guardianship. If you, as an active employee, or your spouse are
not currently enrolled, you may enroll yourself and your spouse when you add a new dependent
child.
If you don’t enroll new dependents within 31 days, you must wait for the next life event (i.e.,
marriage, birth, or adoption), change in employment status, or annual enrollment opportunity to
obtain coverage for the new dependent.
Losing Other Coverage
If you decline coverage for yourself or your dependents because you or your dependents have
other coverage and you or your dependents later lose the other coverage, you and your
dependents may qualify for special enrollment in the Plan if your new enrollment form is
completed within 31 days of the date coverage is lost.
A loss of other coverage qualifies for special enrollment treatment only if one of the following
conditions are met:
•
You, as an active employee, and your dependents were covered under another group
health care plan or group health insurance policy at the time you were eligible for
coverage from your employer;
•
You, as an active employee, and your dependents lost the other coverage because
you/they exhausted COBRA continuation coverage, were no longer eligible under that
plan, or an employer’s contributions for coverage under that plan stopped; or
•
Your dependent child lost other group health plan coverage for any reason.
Special Rules for Retirees if Covered Under the Plan
If you are a retiree, you may drop your coverage at any time during the year without a qualifying
life event. Retirees who drop their coverage under the Plan are not permitted to re-enroll in that
coverage.
Dependents of retirees are eligible for special enrollment upon marriage or acquisition of a new
dependent by marriage, adoption, birth, placement for adoption, or legal guardianship if the
retirees are currently enrolled in the Plan.
Please keep in mind: Retirees and dependents of retirees are not eligible for special enrollment
opportunities due to loss of eligibility of other coverage.
Special Rules for Directors and Retained Attorneys if Covered Under the Plan
If you are a director or a retained attorney and covered under this Plan, you may drop your
coverage at any time during the year without a qualifying event. Directors and retained attorneys
who drop coverage may re-enroll in that coverage during their employer’s annual enrollment
period or within 31 days of a life or employment event.
Special Enrollment Rights Under CHIP
Under the Children’s Health Insurance Program (CHIP) Reauthorization Act of 2009, you and
your dependents (if dependents are covered under this Plan) may be eligible for a special
opportunity to enroll in (or withdraw from) the Plan, as applicable, under the following
conditions:
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•
If you or your dependents lose coverage under your State CHIP or Medicaid program,
you may be able to enroll yourself and your dependents in this Plan, provided that you
request enrollment within 60 days after the termination of your State CHIP or Medicaid
coverage.
•
If you or your dependents become eligible for a premium assistance subsidy under your
State CHIP or Medicaid coverage, you may be able to enroll yourself and your
dependents in this Plan, provided that you request enrollment within 60 days after
eligibility is determined.
•
If you or your dependents become eligible for coverage under your State CHIP or
Medicaid program, you and your dependents have the right to withdraw from this Plan
the first day of the month after you give notice to your employer.
Qualified Medical Child Support Order
The Plan extends benefits to an employee’s non-custodial child, as required by any qualified
medical child support order (QMCSO), under ERISA § 609(a), to the extent such child is
otherwise eligible to be covered under the Plan. The Plan has procedures for determining
whether an order qualifies as a QMCSO. Participants and beneficiaries can obtain, without
charge, a copy of such procedures from the Plan Administrator.
When Coverage Ends
Your and your dependent’s eligibility for Plan benefits terminates:
•
When you terminate employment with your employer. (Please see your Benefits
Administrator for the exact date your coverage ends.);
•
If you fail to pay your share of the premium;
•
If your hours drop below the required eligibility threshold;
•
If you are no longer in the group of individuals eligible to participate in the Plan;
•
If you or your dependents submit false claims;
•
If you or your dependents misuse your Plan identification card (see Misuse of Plan ID
Card below);
•
If you or your dependents intentionally misrepresent a material fact concerning coverage
or benefits;
•
If the Plan terminates; or
•
If the Employer terminates its participation in the Plan.
Coverage for your spouse and children (if covered) ends when your coverage ends, or when their
eligibility for coverage ceases for other reasons, such as divorce or when a child no longer
qualifies as a dependent under the Plan.
HIPAA Certificate of Creditable Coverage
The Plan will provide you and/or your dependents with a HIPAA Certificate of Creditable
Coverage (HIPAA Certificate) when you and/or your dependents cease to be covered under the
Plan, including when you are eligible for COBRA continuation coverage. In addition, you may
request a HIPAA Certificate from the Plan by contacting NRECA’s Employee Benefits Services
(EBS) at:
Employee Benefits Services
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P.O. Box 6338
Lincoln, NE 68506
Phone: (866) 673-2299
FAX: (402) 483-9362
EBS will mail, fax, or email the requested HIPAA Certificate according to your instructions.
Misuse of Plan ID Card
The identification card issued by the Plan to you and your dependents is for identification
purposes only and for use only by you and your covered dependents. Possession of an
identification card confers no right to services or benefits under this Plan. Misuse of such
identification card may be grounds for termination of your coverage, as described above.
Continuation Coverage
If coverage under the Plan for you, your eligible spouse, or your eligible children ceases because
of certain “qualifying events” (for example, termination of employment, reduction in hours,
divorce, death, child’s ceasing to meet the plan’s definition of dependent) specified in a federal
law called COBRA, then you, your eligible spouse, or your eligible children may have the right to
purchase continuing coverage under the Plan for a limited period of time (see “COBRA”
section).
Continuation and reinstatement rights may also be available if you are absent from employment
due to service in the Uniformed Services pursuant to the Uniformed Services Employment and
Reemployment Rights Act of 1994 (USERRA) (see “USERRA” section).
Chapter 4:
Medical Benefits
How the Plan Works
Covered charges for Physicians’ visits, Hospital, surgical, and other medical expenses, will be
paid by the Plan at the coinsurance rate elected by your employer, subject to Reasonable and
Customary (R&C) Rates (see Definitions) for eligible out-of-network services, deductible, and
your annual out-of-pocket (OOP) coinsurance maximum (See “Chapter 2”). Once you have
reached the annual OOP coinsurance maximum, your eligible expenses are paid by the Plan at
100% (subject to R&C Rates or any applicable copayments) for the remainder of the calendar
year.
Because medical claims are processed by CBA and prescription drug claims by CVS Caremark
(see “Chapter 6”), the potential exists for a lag time before your total out-of-pocket expenses are
updated. As a result, you may be asked to make a payment for either a medical expense or a
prescription drug expense even if you have actually met the annual OOP coinsurance maximum.
If this occurs, a refund will be issued by CBA.
This Plan provides medical benefits and services. The section entitled “Medical Services Covered
Under the Plan” provides a detailed listing of the services covered under the Plan.
Under the Plan, you may choose to visit any Physician.
In-Network PPO Discounts
This Plan affords you and your family certain discounted coverage through In-Network medical
services. With the Plan, you may go to any health care providers you wish. However, if you use
health care providers who are in the Plan’s primary PPO network—these are known as preferred
providers—you will receive greater benefits than if you go to other providers, and there will be
no claim forms to fill out.
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The primary PPO network(s) that you have access to are shown on the front of your medical ID
card. In some cases, you will have a local primary PPO and an out-of-area primary PPO
network. The PPO logo and phone number for the primary PPO network(s) appear on the
front of your Plan ID card.
To help keep the plan affordable, NRECA has partnered with supplemental provider networks
to gain discounts for you on out-of-network services. Each supplemental network has a group
of participating acute-care Hospitals, ancillary providers, and practitioners that grant discounts
on out-of-network services. The Explanation of Benefits will reflect the network discount.
There are several ways for you to find out which providers participate in the Plan’s network—
Please see your Benefits Administrator or refer to your current ID card for specific information
regarding your Plan’s network.
Call your primary PPO network’s phone number that is listed on your medical ID card.
You can review a list of preferred providers by going online. See your Benefit Administrator for
the web site address that applies to your situation.
You can also call CBA (see “Chapter 1”) for assistance.
Your Benefits Administrator has a list of preferred providers and will provide you with the list—
without charge—when you first enroll.
Keep in mind: While the list of preferred providers is updated periodically, it changes
frequently. It is a good idea to call your primary PPO Network ahead of time to confirm that
your provider still participates in the network.
Please keep the following facts in mind concerning the primary and supplemental PPO
networks:
•
PPO network Physicians and Hospitals are not affiliated with—and have not been
selected by—your employer. Network providers have no contract with your employer.
The Plan pays PPO network Physicians according to contracted rates, and these rates
apply only to network providers;
•
Neither the Plan nor your employer provides or guarantees the quality of the health care
that you or a covered dependent receive under the Plan; and
•
You always have the choice of what services you receive or who provides your care—
regardless of what the Plan covers or pays.
When In-Network Benefits are Paid for Out-of-Network Providers
For an inpatient/outpatient surgical admission:
•
if the Hospital or facility is in the primary PPO network and
•
the surgeon is in the primary PPO network,
then covered services rendered by ancillary providers (such as surgical assistants,
anesthesiologists and radiologists) are covered at the in-network benefit level. Benefits for
covered services rendered by all other specialists (such as cardiologists and oncologists) are paid
according to their participating status with the PPO.
For an inpatient Hospital admission:
•
if the Hospital or facility is in the primary PPO network and
•
the admitting Physician is in the primary PPO network,
14
then all the covered charges for ancillary services during that admission are covered at the innetwork benefit level. Again, this excludes other medical specialists.
Covered emergency room charges associated with an actual Medical Emergency will be covered
at the in-network benefit level.
When Medicare is primary to your NRECA Plan for purposes of coordinating benefits with
Medicare, the medical benefits under your NRECA Plan are always covered at the in-network
PPO benefit level under your NRECA Plan.
In all other cases, the benefit level is determined by the participating status of the provider
rendering the service.
What the Plan Covers
The Plan covers medical services as outlined described in Chapter 2 and described below in
“Medical Services Provided Under the Plan”. The medical coverage provided under the Plan is
subject to certain expenses you pay out of your pocket. This includes the following:
The Deductible
A deductible is the amount you or a covered dependent pay in eligible health care expenses in a
calendar year before the Plan begins to pay benefits. The annual deductible applies to all services
except preventive services (see “Preventive Care Benefits and Screenings”).
Your in-network and out-of-network deductibles (see “Chapter 2”) are actually a combined
deductible. Amounts credited toward satisfying the in-network deductible count toward
satisfying the out-of-network deductible and vice versa.
If your family is enrolled in the Plan, then your family will have a family deductible (see “Chapter
2”). Eligible expenses for all family members count toward the family aggregate deductible.
Keep in mind: The maximum family deductible must be satisfied before the Plan begins
to pay coinsurance – there is no individual deductible if your dependents are covered by
the Plan.
For example:
Pam
$2,000
Spouse
$1,500
Child
$500
$4,000 (family deductible met)
Once the $4,000 has been reached – coinsurance is applicable
for both Pam and the other members of her family. Pam is not
eligible for coinsurance though until the $4,000 is met.
Cost Sharing (Coinsurance)
For most medical treatments and services, you and the Plan will share the cost of medical
expenses once your deductible is satisfied. You will pay a percentage of the cost and the Plan will
pay the remaining percentage of the cost. This is called coinsurance. Generally, in-network
providers are reimbursed at a higher coinsurance level than out-of-network providers.
Annual OOP Coinsurance Maximum
15
There is a limit to how much you and your family must pay toward covered medical treatments
and services in a calendar year. This is known as the annual OOP coinsurance maximum (see
“Chapter 2”).
The following amounts do not count toward the annual OOP coinsurance maximums:
•
The annual deductible (or family deductible, if applicable)
•
Required copayments (if applicable to the Plan)
•
Amounts above R&C Rates;
•
Hospital (see “Definitions”) expenses and non-emergency, outpatient CT or MRI of the
spine and extremities not covered due to failure to obtain precertification through
SHARE (20% penalty) (see “The Simplified Hospital Admission Review (SHARE)
Program”); and
•
Expenses for services not covered by the Plan.
If you have family coverage, once your family has reached the in-network annual family
OOP coinsurance maximum, the Plan will pay 100% of all covered in-network expenses
for all covered family members for the remainder of the calendar year. Once your family
has reached the out-of-network annual family OOP coinsurance maximum, the Plan will
pay 100% of all covered expenses for all covered family members for the remainder of
the calendar year. The family annual OOP coinsurance maximum is the accumulated outof-pocket expenses for all family members. Each individual never has to meet more than
the individual annual OOP coinsurance maximum annually.
Reasonable and Customary (R&C) Rates
Any charges that you or a covered dependent incur from providers that are not in your primary
PPO network(s) are subject to R&C Rates. If your provider charges above the R&C Rates, you
will be responsible for paying any amounts over those limits.
R&C Rates do not apply to services you receive from primary PPO network providers because
in-network providers have pre-negotiated, contracted fees for their services.
Additional Payments
There are some cases where you will need to make additional payments toward the cost of any
medical care you or a covered dependent receive. You should read through this document
carefully and consult it whenever you or a covered dependent need medical care. That way, you’ll
better know and understand what the Plan will pay and what you will need to pay toward the
cost of medical care.
Evaluation of Services
The determination of eligible charges also includes the evaluation of how a service or procedure
is billed. When charges for services or procedures are presented in a format that clearly lists and
bills separately for procedures and/or services that are commonly considered incidental to a
primary procedure or are commonly considered as a combined service or procedure, benefits are
paid based on what is commonly considered as the evaluation of what to charge for the
procedure(s) and service(s) provided. While a Physician (see “Definitions”) has a right to
determine how much to charge for his or her services, the Plan will consider the industry
standard valuation as the manner in which the services would be charged and benefits will be
based on that amount.
16
Medical Services Covered Under the Plan
In order for any medical treatments or service to be provided under the Plan, the Plan must
determine that the medical treatments or services are Medically Necessary Services and Supplies
(see “Definitions”).
Preventive Care Benefits and Screenings
Keep in mind: Preventive care benefits and screening through in-network providers will
be covered at 100%. All out-of-network preventive care benefits and screenings are
subject to coinsurance and R&C Rates (see “Chapter 2”).
The Plan provides coverage for several types of preventive care services. These include:
•
Adult Physical Exams,
•
Well-Child Care Exams, and
•
Age-and Gender-Appropriate screenings, tests and Immunizations (see “Definitions”)
for adults and children.
Adult Physical Examination Benefit
The Plan will cover 1 physical exam every calendar year at 100% for you, your spouse, and
eligible dependents age 19 and older. For women this benefit covers an annual physical in
addition to a well woman exam.
The preventive benefit also provides coverage for standard preventive screenings, tests and
Immunizations that are considered appropriate for the person’s age and gender (see “Age-and
Gender-Appropriate Screenings, Tests and Immunizations for Adults and Children”). These
services must be done on an outpatient basis and may be performed at the same time as an
annual physical exam.
The Plan does not cover physical exams – including DOT exams – that are conditions of
employment, for aviation, and other certain situations. The Adult Physical Examination benefit
is intended to be for comprehensive checkups for the purpose of monitoring your health.
Well-Child Care Benefit
The Plan provides well-child care benefits for your covered child up to his or her 19th birthday.
It covers an unlimited number of well-child exams. This benefit also provides coverage for
standard preventive tests, screenings, and Immunizations that are considered appropriate for the
child’s age and gender (see “Age and Gender Appropriate Screenings, Tests, and Immunizations
for Adults and Children”). There is no dollar limit per visit or per calendar year for well-child
care benefits.
Charges made by a Hospital for services or supplies provided during a Hospital stay are not
covered as well-child benefits.
Age-and Gender-Appropriate Screenings, Tests and Immunizations for Adults and Children
Certain screenings, tests and Immunizations are recommended based on age and gender (e.g., a
colon cancer screening for participants ages 50-74 or a mammogram for women age 40 and
over). If preventive in nature and coded appropriately by the billing provider, these screenings,
tests and Immunizations are covered.
In some cases, where family history warrants a screening earlier than recommended for a
particular health problem, an eligible screening may be covered. Call CBA (see “Chapter 1”) to
verify.
17
Adult Immunizations (for participants who are age 19 and over) include, but are not limited:
• Herpes Zoster (commonly called the shingles vaccine),
• Tetanus,
• Measles,
• Mumps,
• Rubella,
• Influenza (commonly called the flu shot),
• Pneumonia,
• Chicken pox,
• Hepatitis A&B, and
• Lyme disease.
For children from birth to the 19th birthday, please refer to the American Academy of Pediatrics’
(AAP) Recommended Childhood Immunization Schedule at
http://www.aap.org/healthtopics/immunizations.cfm.
Keep in mind: A special Immunization, called Synagis, which is occasionally given to
premature babies, is not covered under the medical benefits of this Plan unless the Plan is billed
by the Hospital during the initial inpatient confinement for a premature newborn; however, it is
covered by the prescription drug benefits of this Plan in certain situations. The drug must be
preauthorized before it is covered and must be filled through CVS Caremark Specialty Pharmacy
Services. Synagis is not included in the AAP Recommended Childhood Immunization Schedule.
The Plan covers screenings and tests for adults and children recommended by the United States
Preventive Services Task Force (USPSTF), and Immunizations for routine use in adults as
recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for
Disease Control and Prevention (CDC). Note that these recommendations are subject to change,
and Plan benefits will change accordingly. These recommended screenings, tests and
Immunization can be found as follows:
•
Preventive Services Recommended by USPSTF –
www.healthcare.gov/center/regulations/prevention/taskforce.html
•
Recommended Adult Immunization Schedule –
www.cdc.gov/vaccines/recs/schedules/downloads/adult/2010/adult-schedule.pdf
Some preventive screenings are not covered due to the lack of clinical evidence for effectiveness
(e.g., routine chest x-rays, full body x-rays). For more information about NRECA’s preventive
benefits, including charts of some key recommended preventive services based on age and
gender, visit the Employee Benefits Website at My Account>My Insurance>Prevention.
If you are unable to access these schedules online and wish to receive a copy of these
recommendations, please contact NRECA’s Member Contact Center at 866-673-2299.
Preventive Services Not Covered
The following screenings, tests and Immunization services are not covered under the Plan or are
covered only under certain circumstances:
SERVICE*:
GENDER: AGE:
POLICY:
Abdominal Aortic Aneurysm
(routine radiology procedure for
detection)
Female
Not covered.
All
18
Abdominal Aortic Aneurysm
(routine radiology procedure for
detection)
Male
0-64
And
76+
Will allow 1 per lifetime for
ages 65 to 76.
Breast Cancer Gene Test
(BRCA)
Both
All
Coverage subject to Medical
Necessity and the Clinical
Policy Bulletin
Lung cancer screening using low
dose computerized tomography
(LDCT), chest x-ray, sputum
cytology, or a combination of
these test
Both
All
Not covered.
Carotid Artery Stenosis (CAS)
(stroke-screening using duplex
ultrasonography, digital
subtraction angiography, or
magnetic resonance
angiography)
Both
All
Not covered.
Peripheral Artery Disease
screening using ankle brachial
index
Both
All
Not covered.
Chronic Obstructive Pulmonary
Disease (COPD) screening using
spirometry
Both
All
Not covered.
Executive physicals (physicals
that include multiple
unnecessary tests that are often
high-dollar and not age and
gender appropriate).
Both
All
Not covered.
Synagis shot to prevent
Respiratory Syncytial Virus
(RSV) infection
Both
Infants
less
than
age 2
Not covered under the
medical benefits unless billed
by the Hospital during the
initial inpatient confinement
for a premature infant. May
be covered under the
prescription drug benefit,
subject to Medical Necessity
review by CVS Caremark
Employment-related physical
exams such as DOT
Both
All
Not covered.
* This list represents services that are not recommended or covered for the general population
who do not exhibit symptoms that demonstrate cause for testing. Diagnostic testing may be
appropriate and covered, but is not covered under the Plan’s Preventive Care provisions. This is
not an all-inclusive list and is subject to change based on evidence and recommendations of the
USPSTF and ACIP of the CDC. If you have questions about the coverage of a service that is
19
not listed in this chart, or any other recommended preventive services, please call CBA (see
“Chapter 1”).
Diabetic Retinopathy Screening
For individuals with a diagnosis of diabetes, the Plan will provide coverage for a diabetic
retinopathy exam and/or diagnostic diabetic retinopathy test(ing) to monitor the eye health of an
individual with diabetes.
Diabetes Self-Care Programs
Participation in a diabetes outpatient medical self-care program is a covered expense under the
Plan (subject to the frequency, duration and coverage limitations described in this section) when
the program satisfies the following criteria:
•
The program is specifically ordered by the Physician treating the participant’s diabetes;
and
•
The program is composed of services provided by healthcare professionals who are
licensed, certified, or qualified by professional credentials or degrees (Physicians,
registered nurses, registered pharmacists, registered dieticians); and
•
The program is designed to educate the participant about Medically Necessary aspects of
diabetes self-care.
To be a covered expense, the expense related to participation in diabetes outpatient medical selfcare programs must be incurred:
•
When the patient has been newly-diagnosed with diabetes; or
•
No more frequently than every 3 years after initial diagnosis; or
•
When a change in the patient’s condition warrants a significant adjustment in treatment
modality. Such changes may include:
o Introducing new medications that may impact blood glucose levels, including
those used in the treatment of other conditions (e.g., corticosteroids)
o Introducing a new class of anti-diabetic medications (adding insulin to oral antidiabetic medications)
o Diagnosis with a separate chronic condition that may impact blood glucose levels
o Stress
o Hospitalization or acute illness
o Gestational diabetes
o Surgery
o Significant change in body mass index (BMI)
The portion of the diabetes outpatient medical self-care program that is Medically Necessary will
vary depending on the goals and objectives of the program, but shall not exceed 10 visits within
a 12-month period up to a maximum of $1,000 in eligible charges. A maximum of 1 day of
follow-up training, not exceeding $250 in eligible charges, will be allowed annually after the initial
training year, when recommended by your Physician. Covered charges for diabetes outpatient
medical self-care programs are subject to the annual deductible and the in-network and out-ofnetwork benefit levels (if applicable for this Plan) for Physician benefits (for surgery, Hospital
visits and services).
20
Participants are strongly encouraged to contact MyHealth Coaches for additional help in
managing their diabetes (see “MyHealth Coaches”).
Physician Services
The Plan will cover services (see “Chapter 2”) provided by a Physician (see “Definitions”).
Covered charges include evaluation and management services only. Physician services include:
•
Office Visits—Visits to a Physician’s office are covered. Covered charges include
evaluation, x-ray and laboratory charges billed by the same Physician on the same day of
service;
•
Surgery, Hospital Visits and Hospital Services—Physicians’ charges for surgery,
Hospital visits and Hospital services are also covered. The Plan will pay benefits toward
surgeon and anesthesiologist fees (inpatient or outpatient); inpatient, outpatient, and
emergency room Physician charges; and second surgical opinions; and
•
Allergy Immunizations—Physicians’ charges for allergy Immunizations are covered.
Treatment of Complications From Non-Covered Procedures
Treatment of complications from medical or surgical interventions is covered by the Plan,
subject to the following coverage rules:
•
The treatment itself must be a service that is covered under the Plan;
•
If the original medical or surgical intervention was not, or would not have been, a
covered service under the Plan, benefits are limited to treatment of the complication
only, if such treatment is a service that is covered under the Plan;
•
Treatment for complications that are the result of experimental or investigational
medications or procedures is a covered benefit; however, the cost of administration or
use of an investigational drug or procedure is not a service that is covered under the
Plan; and
•
The Plan may require a full medical review of the non-covered procedure,
complication(s) and/or subsequent treatment before claims may be paid for treatment of
the complication(s).
Covered expenses for treatment for complications from medical or surgical interventions are
subject to benefit levels for Physician Services (for surgery, Hospital visits and services).
Anesthesia Services and Facility Charges for Dental Services Under Specific
Circumstances
Coverage may be extended under the Plan for the use of deep sedation/general anesthesia for
oral and maxillofacial surgery and dental services provided either in an office or Hospital-based
environment, subject to prior review by CBA. This includes, but is not limited to, the
management of oral rehabilitation in adults with severe physical and/or behavioral abnormalities
who require sedation for this care. No coverage is extended for anesthesia in connection with
any type of dental Cosmetic Procedures (see “Definitions”). Coverage may be extended under
the Plan for anesthesia and facility charges even when the dental procedure itself is not covered
under the Plan. All such coverage is subject to this plan’s usual requirements for coverage,
including, but not limited to, precertification.
Deep sedation/general anesthesia is covered under the Plan under the following circumstances:
•
Radical excision of lesions in excess of 1.25 cm (1/2 in.).
21
•
Radical resection or ostectomy with or without bone graft.
•
Patients exhibiting physical, psychological, intellectual, or medical conditions for which
dental treatment under local anesthesia, with or without additional adjunctive techniques
and modalities, cannot be expected to provide a successful result and which, under
anesthesia, can be expected to produce a superior result. Such conditions include, but are
not limited to, cerebral palsy, epilepsy, cardiac problems and hyperactivity (verified by
appropriate medical documentation).
•
Chronic disability that is attributable to a mental (e.g., mental retardation and Down's
Syndrome) or physical impairment or combination of both; is likely to continue
indefinitely; and results in substantial functional limitations in one or more of the
following: self care, respective and expressive language, learning, mobility, capacity for
independent living and economic self-sufficiency (verified by appropriate medical
documentation).
•
Patients who have sustained extensive oral-facial and/or dental trauma, for which
treatment under local anesthesia would be ineffective or compromised.
Local anesthesia is ineffective because of any of the following:
•
acute infection,
•
anatomic variation (e.g., due to previous surgery, trauma or congenital anomaly), or
•
allergy to local anesthesia.
Diagnostic Lab & X-Ray Services
The Plan provides benefits to cover the cost of diagnostic x-ray and laboratory services that are
necessary for the treatment of sickness or injury (see “Chapter 2”).
Hospital Services
The Plan provides additional benefits for expenses you or a covered dependent incur during a
Hospital Confinement (see “Definitions”).
Keep these factors in mind:
•
The Plan will consider payment for room and board up to the Hospital’s standard rate
for a semi-private room.
•
You must call SHARE with regard to any Hospital admissions—emergency or nonemergency. If you do not, expenses counted as eligible expenses will be reduced by 20%,
and the uncovered Hospital expenses will not be applied to your Annual OOP
coinsurance maximum (see “The Simplified Hospital Admission Review Program (SHARE)”).
•
An emergency admission is an admission to the Hospital for a condition that, unless
promptly treated on an inpatient basis, would put the patient’s life in danger or cause
serious damage to a bodily function of the patient.
•
The Partial Hospitalization Program (PHP) provides a short-term, intermediate level of
care for the treatment of mental health and substance-related disorders. PHPs are
typically offered within a psychiatric Hospital or behavioral health department of a
Hospital. Patients participate generally weekdays for 6 to 8 hours at a time as prescribed
by their Physician. The Plan considers a partial day to count as one (1) inpatient day.
Please see the pre-certification provision in the Computed Tomography (CT) and Magnetic
Resonance Imaging (MRI) section.
22
The Plan covers a variety of benefits for treatment that you or a covered dependent receive in
the Hospital, including:
•
Inpatient care and surgery,
•
Outpatient surgery, and
•
Outpatient services.
Remember: You must call the Simplified Hospital Admissions Review (SHARE) to precertify a non-emergency Hospital admission. It is recommended that you call 2 weeks
before a scheduled admission.
If you have been admitted to the Hospital for an emergency, SHARE must be called
within 2 business days of admission.
If you fail to call SHARE for either an emergency or non-emergency admission,
expenses counted as eligible expenses will be reduced by 20%.
The Simplified Hospital Admission Review (SHARE) Program
Coping with an illness or injury that requires Hospitalization can be stressful, confusing and
costly. Understanding your treatment options and which expenses your Plan will cover are
important. To help you reduce the confusion and costs associated with Hospitalization, the Plan
includes the SHARE Program.
The SHARE Program offers four medical review services to help you make informed health care
decisions:
•
Hospital Confinement Review
The SHARE Program provides a Hospital Confinement Review service by contacting
your Physician as soon as they are notified that Hospitalization has been prescribed. The
SHARE Medical Review Coordinator will evaluate the proposed treatment plan and
make sure that the length of your stay and any recommended convalescent treatment
and/or facilities are medically appropriate.
SHARE Medical Review Coordinator will discuss with your Physician the reason for
your Hospitalization and an appropriate length of confinement. They will then mail a
Hospital admission confirmation to both you and your Physician.
The Hospital admission confirmation approves the medical appropriateness of the
proposed Hospitalization. However, this approval does not guarantee either the payment
of benefits or the amount of benefit. Eligibility for, and payment of, benefits are subject
to all of the terms of the Plan. A Hospital admission confirmation is binding, unless the
information furnished to the SHARE Medical Review Coordinator was misleading.
Under the terms of the Plan, eligible expenses do not include expenses for services or
supplies that are not Medically Necessary. In addition, no benefits are payable for days of
inpatient Hospital Confinement found not Medically Necessary. This could include all
days of inpatient Hospital Confinement or some of them.
23
It may be possible to extend the number of days of inpatient Hospital Confinement
approved as needed for medical care of the patient's condition. You must arrange for the
patient's Physician to request such an extension by phoning the SHARE Medical Review
Coordinator before the previously approved length of stay is over.
When the request is made, the SHARE Medical Review Coordinator will make a new
determination of need on the basis of information given by the Physician. The Physician
will be told how many days, if any, are approved as needed for medical care of the
patient's condition. This will be confirmed by written notice sent to you, to the Physician,
and to the Hospital.
If your pre-admission review or determination of need is not approved by SHARE, you
have a right to appeal the decision (see “Chapter 5”).
•
Medical Case Management
If a Hospital admission has the potential for requiring long-term care, a SHARE case
manager will be assigned to you. A SHARE case manager provides guidance and
information on available resources. The patient and family select the most appropriate
treatment plan and the SHARE case manager coordinates and implements the program.
Medical Case Management is a voluntary service. There are no reductions of benefits or
penalties if you choose not to participate. Medical decisions are made by you and your
Physician and do not involve the Plan.
•
Discharge Planning
SHARE monitors your progress in the Hospital and when you need continuing care after
your release, SHARE works with the Hospital to arrange your transfer to an extended
care facility, nursing home or your own home. In order for the Plan to cover these
transportation services, CBA must determine the transportation to be Medically
Necessary. SHARE also arranges for wheelchairs, Hospital beds, home care nurses,
pharmaceuticals and other health aids. Through Discharge Planning, SHARE monitors
your treatment and progress throughout recovery.
•
First Steps Maternity Program
Through enrollment in the First Steps Maternity Program, expectant mothers have access
to a highly specialized maternity program designed to promote early identification of risk
factors during pregnancy and to emphasize prenatal care through educational brochures.
The available literature outlines proper prenatal care, diet, the signs of pre-term labor
complications and the dangers associated with drugs, alcohol and smoking.
To access the First Steps Maternity Program, an expectant mother should call to enroll at
800-526-7322 during the first trimester or as soon as she knows she is pregnant. The call
is free of charge and completely confidential. A maternity specialist will explain how the
maternity program works and how it can help protect both her and her baby’s health.
The SHARE Program is designed to review and coordinate treatment and to assist you in
making informed decisions about medical treatment and the use of the Plan. SHARE helps you
reduce the risks and costs of unnecessary Hospitalization and medical care by choosing the
safest, most appropriate course of treatment. However, medical decisions are ultimately made by
the patient and your Physician and do not involve the Plan.
Contacting SHARE:
24
The SHARE toll-free number is 800-526-7322. Calls received before 8:00 a.m. and after 7:00
p.m., Eastern Time, and on weekends will be recorded and returned the next business day.
The address of the SHARE Medical Review Coordinator is:
Carewise Health/SHPS
9200 Shelbyville Road, Suite 100
Louisville, KY 40222-5149
In non-emergency situations, you should call SHARE about two weeks prior to the scheduled
admission.
In emergency situations, SHARE must be notified within 2 business days after your
admission. This includes non-business hours but excludes weekends and U.S. Government
holidays. For example, if you are admitted to a Hospital for an emergency at 9 p.m. on Friday,
you must call SHARE by 9 p.m. on Tuesday.
Anyone—the patient, a family member, the Physician, or the Hospital—may call SHARE for
either an emergency or a non-emergency Hospital admission. However, please keep in mind that
it is the responsibility of the patient or the patient’s family to notify SHARE.
Between 8:00 a.m. and 7:00 p.m., Eastern Time, Monday through Friday, you can talk with a
SHARE Medical Review Coordinator (a registered nurse), who will ask for:
•
Your name,
•
The name, address and phone number of your attending Physician,
•
Your group insurance coverage number, and
•
Your employer’s name.
Calls placed at other times will be recorded, and a SHARE Medical Review Coordinator will
return the call the next business day.
Remember: No one is required to use the SHARE Program. If you do not use the
SHARE Program, the amount of Hospital expenses counted as eligible expenses will be
reduced by 20% and the uncovered Hospital expenses will not be applied to your out-ofpocket coinsurance maximum or deductible.
For example, if you go into the Hospital and incur charges of $10,000 that would
normally be eligible expenses under the Plan, but you failed to call SHARE, your eligible
expenses would be reduced by 20% ($2,000), making your eligible expenses for the
Hospital stay $8,000 ($10,000 - $2,000). The $2,000 in uncovered Hospital expenses
would have to be paid out of your own pocket and cannot be applied to your annual outof-pocket coinsurance maximum or deductible.
Inpatient Care
The Plan covers the following for inpatient Hospital care:
•
Room and Board—The plan will cover eligible charges for room and board in a semiprivate room.
25
Any charges above the semi-private room rate will not be paid by the Plan. If the
Hospital does not have semi-private rooms, the limit will be the daily charge for its
lowest-rate private room.
•
Other Hospital Services—The following are covered in the same manner as room and
board charges for:
o Services and supplies that are furnished by the Hospital such as operating room,
x-rays, lab tests, medicines, etc. (but not professional services such as Physician’s
visits and second opinions—they are covered as Physician charges, not Hospital
charges);
o Ambulance service to the nearest appropriate facility if the patient is admitted to
the Hospital; and
o Pre-admission x-ray and lab tests.
Please note that separate Hospital Confinements that are due to the same illness will be
considered one confinement unless they are separated by at least 14 days.
Eligible Surgical Expenses
A wide variety of Physicians’ surgical services are covered under the Plan. For example,
performance of the following surgical procedures is covered (excluding oral surgery):
•
Incision, excision or electro-cauterization of any organ or body part
•
Reconstruction of any organ or body part or the suture repair of lacerations
•
Reduction of a fracture or dislocation by manipulation under general anesthesia
•
Use of endoscope to explore for or to remove a stone or other object from the larynx,
bronchus, trachea, esophagus, stomach, intestine, urinary bladder or ureter
•
Puncture and aspiration
•
Injection for contrast media testing
•
Laser surgery
•
Treatment of burns
•
Application of casts.
In addition, the Plan will cover:
•
Assistance with the surgical procedure where it is required because the individual is not
in a Hospital with available, qualified Physicians. Charges for surgical assistants will be
limited to 20% of the R&C Rate of the surgeon’s fee.
Outpatient Surgical Expenses
The Plan covers fees for an outpatient facility when surgical procedures are performed by a
Physician on an outpatient basis. The Plan will consider benefits as indicated in Chapter 2 toward
the cost of the facility’s fees.
Outpatient surgical procedures may be performed in a Hospital, a freestanding surgical facility or
an Ambulatory Surgical Center (see “Definitions”).
Expenses covered under another part of this Plan (such as a Physician’s fees for the surgery) are
covered under the provisions of that part of the Plan and not as outpatient surgical expenses.
26
Surgical Expenses Not Covered by the Plan
The following surgical expenses are not covered by the Plan:
•
Surgeries that are investigational or experimental in nature
•
Cosmetic Procedures, unless it is due to a congenital defect that impairs the function of a
body organ, or an Accident (see “Definitions”).
Mastectomy Expenses Covered by the Plan
See “Chapter 11” for more information.
Ambulance Charges
The Plan provides benefits for the use of ambulance services (see “Chapter 2” – what the Plan
pays for Hospital Services).
Ambulance service must be to the nearest appropriate medical facility qualified to treat the
person’s sickness or injury. Use of the ambulance must be Medically Necessary and must be the
most reasonable method of transportation available. This includes air ambulance service in the
event of immediate admission to a medical facility and a life-threatening condition as determined
by CBA.
For certain participants residing in Alaska: Ambulance services include non-emergency
commercial airline trips that are made to obtain medical care in non-emergency situations when
the medical care cannot be provided in the locality where the Employer is located and the service
is at the written recommendation of a Physician. Up to $300 round trip, coach fare is covered for
the first trip, and 80% of up to the first $250 of round trip, coach fare is covered for subsequent
trips. Not more than four (4) non-emergency commercial airline trips are covered by the Plan
per calendar year. Please see your Benefits Administrator to see if you qualify for this service.
Emergency Room Services
The Plan provides benefits (see Chapter 2) for the use of a Hospital’s emergency room.
Emergency room services, however, are very expensive and should be used only in a Medical
Emergency (see “Definitions”).
Emergency services include medical screening examinations that are within the capability of the
emergency department to evaluate such Emergency Medical Condition (see “Definitions”); and
such further medical examination and treatment, to the extent they are within the capabilities of
the staff and facilities available at the Hospital, to stabilize you or your dependents.
If the Plan requires a copayment for emergency room visits (see “Chapter 2”), the copayment
will be waived if your or your dependents are admitted to the hospital.
When you go to an emergency room, you must present the person’s NRECA Medical ID
card to the Hospital. If the person is admitted to the Hospital, be sure to call SHARE
within 2 business days of the admission.
Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)
The Plan requires pre-certification through SHARE for non-emergency, outpatient Computed
Tomography (CT) and Magnetic Resonance Imaging (MRI) of the spine and extremities for
adults and dependent children age 19 and older.
27
Your Physician should call the SHARE program for pre-certification in advance of an outpatient
CT or MRI of your spine, knee, shoulder, hip, or other extremity. Failure to pre-certify these
outpatient radiological procedures will result in a 20% reduction of eligible expenses. These
uncovered expenses will not apply to your deductible or your annual out-of-pocket coinsurance
maximum. It is your responsibility to ensure your Physician calls SHARE to pre-certify your
outpatient CT or MRI of the spine or extremities.
When your Physician calls to pre-certify an outpatient CT or MRI, they will need to provide a
diagnosis and procedure code for your radiological procedure, along with the patient’s name,
member number, group number, employer name, and the provider’s contact information.
For more information regarding SHARE, please see “The Simplified Hospital Admission Review
(SHARE) Program”.
Organ and Tissue Transplant Services
Keep in mind: You are required to use the NRECA Managed Transplant Centers of
Excellence (COE) Program if you are a transplant candidate. If you choose not to use the
COE Program, the Plan will not cover the cost of the transplant or transplant-related
services.
The Plan will cover solid organ, bone marrow, and peripheral stem cell transplants provided
these charges are deemed Medically Necessary and you use the Managed Transplant COE
Program. When there is a live donor, the Plan will cover the health services associated with the
removal of the organ and/or tissue when performed at the recipient’s selected Managed
Transplant COE facility. Donor expenses may be subject to coordination of benefits with the
donor’s primary medical plan. Deductible, copayment, and coinsurance provisions (if applicable
to your Plan) will apply to transplant-related services. Charges for services provided by a
Managed Transplant COE facility will be covered by the Plan (but will still be subject to all other
Plan limitations and provisions). Benefits for transplants, regardless of whether the Plan is the
primary or secondary payor, are available only from practitioner(s) within the Managed
Transplant COE Program’s designated COE network with case management by the Plan’s
contracted vendor for these services.
COEs are state-of-the-art medical facilities. The Managed Transplant COE network includes
Hospitals and other medical centers that specialize in solid organ and tissue transplants. Some
facilities specialize in one kind of transplant procedure, while others have multiple specialties.
The Plan will cover Medically Necessary transplant services only when provided by facilities that
are designated by the Plan’s contracted vendor as COEs for the applicable transplant procedure.
The practitioners within the Managed Transplant COE Program emphasize quality and
improved outcomes for transplant procedures. The Program includes dedicated case managers
who serve as patient advocates throughout the process and will work with the patient to
determine the most appropriate COE facility. Prescription drugs provided in connection with
the Managed Transplant COE Program are managed through your prescription drug benefits
outside of the medical benefits of the Plan.
The Managed Transplant COE will register the patient with United Network for Organ Sharing
(UNOS), which places the patient on the UNOS regional transplant list. If the needed organ is
rarely donated or difficult to procure, or if the patient has a critical need for an organ to sustain
life, the Managed Transplant COE Program case manager may refer the patient to a COE facility
in a second UNOS region to be placed on the transplant list.
The transplantation period is defined as the day of transplantation through three hundred sixtyfive (365) days following the surgery. When CBA deems that a transplant is Medically Necessary
(and the Managed Transplant COE Program is used), transplant benefits begin with the first
28
appointment with the Physician or COE facility and continues through the transplantation
period. Note: The patient must be sober of drugs and/or alcohol for a minimum of 6 months
before the Plan will begin covering transplant-related expenses and will not cover transplantrelated expenses during the 6-month period prior to drug and/or alcohol sobriety.
If the patient is referred to a facility that loses its Centers of Excellence status for any reason
prior to or during the benefit period, the patient will be directed to another facility that is in the
COE network. This may mean that the patient will need to relocate to be near the COE facility.
The Plan’s transplant travel benefits begin when the patient is referred to a COE facility for
evaluation and ends three hundred sixty-five (365) days following the surgery.
If traveling more than 50 miles from the patient’s home for care at a COE facility, the
transplant recipient and one companion, who is traveling on the same day and time to
and/or from the Managed Transplant COE with the patient (2 companions if the
Participant is a minor) will be eligible for travel benefits of up to a maximum of $10,000
for the Benefit Period subject to reimbursement limitations below (see “Centers of
Excellence Travel Benefits”). In the case of a live donor, the donor and one companion, who
is traveling on the same day and time to and/or from the Managed Transplant COE with the
donor (2 companions if the donor is a minor) will be eligible for travel benefits. These travel
benefits will be deducted from the transplant recipient’s maximum $10,000 travel benefit for the
Benefit Period and are subject to the reimbursement limitations (see “Centers of Excellence
Travel Benefits” below).
As soon as your, or your covered dependent’s, medical practitioner indicates the need for a
transplant or evaluation for a transplant, contact CBA (see “Chapter 1”). CBA will put you in
contact with a dedicated case manager at the Plan’s contracted vendor for these services.
Bariatric Resource Services
The NRECA Bariatric Services Centers of Excellence (COE) Program is a designated COE
program provided by the Plan’s contracted vendor for these services. Keep in mind: The
Bariatric Services COE Program is a mandatory program to assist Plan participants in getting
approval for bariatric surgery. Benefits for bariatric surgery are available only from practitioner(s)
within the Bariatric Services COE Program’s designated COE network with case management
provided by the Plan’s contracted vendor. Charges for services provided by a Bariatric Services
COE facility will be covered by the Plan (but will still be subject to all other Plan limitations and
provisions). Deductible, copayment, and coinsurance provisions (as applicable to your Plan) will
apply to bariatric services.
Bariatric surgeries must be performed at COE facilities designated by the Plan’s contracted
vendor with approved COE practitioners. The facilities and practitioners within the Bariatric
Services COE Program emphasize quality and improved outcomes for bariatric procedures.
Once a participant has been approved for bariatric surgery, the Plan’s contracted vendor will
provide:
•
a choice of credentialed facilities across the country in which the bariatric surgery may
be performed,
•
personalized case management support before and during surgery, and
•
continued support during the post-surgical recovery period.
Personalized case management is provided by the Plan’s contracted vendor with dedicated case
managers who serve as patient advocates throughout the process and will work with the patient
to determine the most appropriate surgical facility. Note: The Bariatric Services COE Program
29
case manager will discuss the bariatric surgery process and will answer questions regarding COE
referrals, and outline the specific criteria and requirements to be eligible to participate in the
Bariatric Services COE Program. The COE surgeon will determine whether the patient is a
surgical candidate.
The Plan may also cover meals, lodging and transportation for the patient and a companion
during the patient’s evaluation, surgery, and follow-up care when traveling a distance of more
than 50 miles from the patient’s home to the facility. The travel benefit period begins once the
patient is referred to a COE facility. The travel benefit is limited to $2,500, and is subject to
expense reimbursement limitations (see “Centers of Excellence Travel Benefits” below).
The following services will not be eligible for benefits under the Plan at any time:
•
services for surgical follow-up care for a bariatric surgery not covered by the Plan;
•
bariatric surgery for a patient who has had previous bariatric surgery, whether or not the
previous bariatric surgery was covered by the Plan;
•
bariatric surgery for a patient under the age of eighteen;
•
unapproved bariatric surgeries;
•
surgeries performed at facilities other than those designated as COEs by the Plan’s
contracted vendor; or
•
surgeries that are not coordinated or managed by the Plan’s contracted vendor.
To inquire about the NRECA Bariatric Services COE Program, contact CBA (see “Chapter 1”).
Once the decision is made to proceed with bariatric surgery, CBA will notify the Plan’s
contracted vendor to begin coordinating pre-surgery and case management services.
Cancer Centers of Excellence Program
Keep in mind: The Plan’s Cancer Centers of Excellence (COE) Program is an optional
program provided to Plan participants by the Plan’s contracted vendor(s). The Cancer COE
Program covers all cancer diagnoses and is strongly recommended for participants who have
complex or rare types of cancer. Treatment which is considered experimental, investigational or
in a trial phase will not be covered under the Plan.
Keep in mind: To be eligible for the Cancer COE Program, your primary insurance plan must
be the NRECA Medical Plan. If Medicare, or another insurance carrier, is your primary
insurance plan and the NRECA Medical Plan is your secondary insurance plan, then the
coverage of cancer care and treatments will be managed by Medicare or your primary insurance
carrier.
When a Participant has been approved for cancer treatment, the Plan’s contracted vendor will
provide personalized case management support during a 365- day continuous treatment period.
As part of the case management services, the Plan’s contracted vendor will provide the
opportunity for the patient to enroll in the Cancer COE Program and provide information about
the many Cancer COE Program-credentialed medical centers across the country in which the
cancer treatments may be performed.
Charges for services provided by a Cancer COE facility will be covered by the Plan, but will be
subject to all other Plan limitations. Charges for services provided by a Cancer COE facility will
be covered at the in-network level (but will still be subject to all other Plan limitations and
provisions). Coverage of charges incurred at facilities other than a Cancer COE is subject to the
Plan’s in-network/out-of-network provisions that would otherwise be applicable. The Benefit
Period begins when the patient is enrolled in the Cancer COE Program and continues for up to
30
365 days or until the patient goes into remission, or until the patient ceases active treatment –
whichever occurs first. In case where active treatment continues beyond 365 days, continuation
of benefits will be considered on a case-by-case basis.
If traveling more than 50 miles from the patient’s home for care at a Cancer COE, the
patient and one companion (2 companions if the Participant is a minor), who is traveling
on the same day and time to and/or from the Cancer COE with the patient, will be
eligible for travel benefits of up to a lifetime maximum of $5,000, subject to guidelines
and reimbursement limitations (see “Centers of Excellence Travel Expenses”). Travel
benefits require all of the following:
•
active participation in the case management services provided by SHARE,
•
actual use of a Cancer COE for initiation and/or development of a cancer treatment
plan, and
•
that the patient be newly diagnosed or in active treatment, which includes:
o diagnosis/evaluation visit,
o active cancer treatments at a Cancer COE facility, and
o follow-up visits to the treating Physician during the course of cancer treatment.
Centers of Excellence Travel Benefits
Travel benefits for bariatric services, organ and tissue transplant services or through the cancers
COE apply to round-trip transportation for the evaluation, COE procedure, and follow-up visits
to the treatment facility completed within the applicable benefit period ( for more information
see “Bariatric Services”, “Organ and Tissue Transplant Services” or “Cancers Centers of
Excellence Program”). The travel benefit covers reasonable and necessary expenses for lodging
and meals for the patient (while not confined) and one companion during the applicable benefit
period. The patient must be actively involved in the travel, meals and lodging for the benefit to
apply – without the patient’s accompaniment – travel benefits are not applicable. Expenses for
companion(s) traveling separately are ineligible for reimbursement. Follow-up care and medical
appointments after the benefit period has ended are not included in this benefit.
Reimbursement limitations include the following:
•
If traveling to the COE treatment location by automobile, the patient will be reimbursed
for the actual mileage completed from the patient’s home to and from the COE
treatment location at a rate per mile equal to the then current IRS standard mileage
allowance for medical reimbursement. Reimbursement will not be provided for tolls,
parking, gas, rental car, or tips. Mileage will only be reimbursable for the most direct
route between the patient’s home and the COE treatment location.
•
When traveling by airplane or by train, the patient and one companion, who is traveling
to/from treatment on the same day/time with the patient, should request
coach/economy seating. If the patient and companion wish to upgrade to a higher fare
status, the patient and companion must pay the difference between the coach/economy
and upgraded fares. Checked baggage fees will be reimbursed for up to 2 bags. Personal
amusement expenses during air or train travel will not be reimbursed (including reading
materials, in-flight movies, games, etc.). An original itemized receipt, or a legible copy,
for travel expenses must be submitted with the transportation expense report for
reimbursement. Travel also includes taxi or ground transportation to and from the
airport or train station to the COE location.
31
•
The maximum combined reimbursement for the patient and companion(s) meals and
lodging may not exceed a total of $200 per day.
•
The patient and one companion lodging benefit covers hotel/motel, camp grounds,
extended-stay residences and Hospital-affiliated residences. Hotel/motel, extended-stay
residences, and Hospital-affiliated residences are limited to one room, double occupancy.
The Plan does not reimburse for personal expenses incurred while using the lodging
benefit. The original lodging receipt, or a legible copy, must be attached to the lodging
expense report for reimbursement.
•
The meals benefit covers food and non-alcoholic beverages for the patient and one
companion (2 if the patient is a minor) on the days that the patient is traveling to and
from treatment, and on the days that the patient is receiving treatment at the COE
treatment location. If the patient chooses to lodge in a location that allows for self
preparation of meals, the benefit will pay for groceries from the following food groups:
meat, dairy, grain, fruits/vegetables. Original itemized receipts, or legible copies, for
meals must be attached to the meals expense report for reimbursement.
•
Examples of personal expenses excluded from meals and lodging reimbursement include,
but are not be limited to, alcoholic beverages, snack foods (sports drinks, bottled soft
drinks, candy, desserts, etc.), haircuts, movies, internet access, massages, laundry, tips,
toothbrushes, toothpaste, cleaning supplies, personal hygiene supplies, and health club
access.
Childbirth Services
The Plan pays benefits for a pregnant mother in the same way that it pays benefits for any nonmaternity illness.
If you request to cover a newborn (whether your natural child or one for whom adoption is
being processed) within 31 days of the birth of the child, coverage will automatically be effective
on the date of birth.
•
Hospital Charges
Charges for service and supplies for a newborn baby will be considered separate from
the mother’s expenses. Charges incurred by the newborn will be considered only if the
newborn is an eligible dependent. You have 31 days following the birth of the child to
add the newborn to your coverage.
•
Birthing Center Charges
Alternatively, expenses at a Birthing Center (see “Definitions”) are also covered by the
plan, provided those services and supplies would have been covered if furnished in a
Hospital.
•
Length of Stay in the Hospital
Group health plans and health insurance issuers generally may not, under the Newborn
and Mother’s Health Protection Act of 1996 (NMHPA), restrict benefits for any
Hospital length of stay in connection with childbirth for the mother or newborn child to
less than 48 hours following a vaginal delivery, or less than 96 hours following a
caesarean section. However, Federal law generally does not prohibit the mother’s or
newborn’s attending provider, after consulting with the mother, from discharging the
mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case,
plans and issuers may not, under Federal law, require that a provider obtain authorization
32
from the Plan or the insurance issuer for prescribing a length of stay not in excess of 48
hours (or 96 hours).
The Plan conforms to the requirements of the NMHPA. However, to avoid a possible reduction
in benefits, the provider should get approval from SHARE in advance for the patient to stay
beyond those limits.
Convalescent Nursing Home Care Service
The Plan provides benefits for Convalescent Nursing Home (see “Definitions”) care following
certain Hospitalizations. A 90-day limit applies to coverage for all Convalescent Nursing Home
care due to the same or related causes.
The Plan provides benefits for eligible expenses incurred during a covered Convalescent Nursing
Home care confinement after an inpatient Hospital stay of at least one day that was covered by
the Plan. The confinement must start within 15 days after release from the Hospital and must be
recommended by the Physician attending the condition causing the Hospitalization. There are 2
types of benefit coverages available:
•
Room and board charges for Convalescent Nursing Home care. Charges for room and
board are limited to 80% of the standard (most common) semi-private room rate of the
Hospital stay that immediately preceded transfer to skilled nursing care.
•
Ancillary services and supplies are services and supplies (other than personal items)
that are furnished by Convalescent Nursing Home for Medically Necessary care while
the patient is under the continuous care of a Physician and requires 24-hour skilled
nursing care.
Remember: Convalescent Nursing Home care must be pre-authorized. Don’t forget to
call SHARE. Otherwise the amount of expenses that are considered eligible expenses
will be reduced by 20%.
Custodial Care (see “Definitions”) is not covered under this Plan.
Hospice Care Services
The Plan provides benefits (see “Chapter 2”) for hospice care as well as benefits for
bereavement. The primary care Physician must give certification of the Terminal Illness (see
“Definitions”) to CBA. Benefits will be paid if the hospice stay or the hospice services are:
•
Provided while the Terminally Ill person is covered under the Plan;
•
Ordered by the supervising Physician as part of the Hospice Care Program (see “Hospice
Care Program”) (see “Definitions”);
•
Charged for by the Hospice Care Program; and
•
Provided within six months of the Terminally Ill person's entry or re-entry (after a
remission period) in the Hospice Care Program.
Hospice Care Program
A Hospice Care Program is a formal program directed by a Physician to help care for a
Terminally Ill person.
A hospice team is a group of professionals and volunteer workers who provide care to:
33
•
Reduce or abate pain or other symptoms of physical or mental distress; and
•
Meet the special needs arising out of the stresses of the Terminal Illness, dying, and
bereavement.
The team includes at least a Physician and registered nurse and could also include a social
worker, a clergyman/counselor, volunteers, a clinical psychologist, physiotherapist, or an
occupational therapist.
Services That Are Covered
The Plan will cover hospice and bereavement charges as follows:
•
Hospice Charges— The Plan will pay benefits for hospice care as outlined in Chapter
2. The Plan will cover eligible covered charges for hospice care up to a lifetime maximum
of $15,000. Eligible hospice charges for this purpose include both inpatient and
outpatient charges.
•
Bereavement Charges—The Plan will pay benefits for bereavement. The Plan will
cover eligible charges for bereavement services for the family unit up to a maximum of
$200. These benefits are for charges incurred for counseling services for the family unit,
if ordered and received under the Hospice Care Program. A family unit is considered to
be you and your covered dependents.
The benefits for bereavement will be paid if two conditions are met:
•
On the day prior to death, the Terminally Ill person was:
o in the Hospice Care Program,
o a member of the family unit, and
o a covered individual; and
•
The charges are incurred by the family unit within three months following the date the
Terminally Ill person dies.
Hospice Services Not Covered
The following services are not covered:
•
Charges for the treatment of a diagnosed sickness or injury of you or your dependent if
the benefits are payable under another part of the Plan. If benefits for such coverage are
expressed as a percent of charges, this exclusion will apply at a rate of 100%;
•
Charges for services provided by you or your spouse, or someone related to you or your
spouse by blood or marriage; or
•
Charges incurred during a remission period. This applies if, during remission, the
Terminally Ill person is discharged from the Hospice Care Program.
Other Medical Services
The following medical services will be covered by the Plan as specified in Chapter 2 in the
Medical Highlights under “Other Medical Services”:
•
Chemotherapy and Radiation Therapy
The Plan will cover eligible charges for Chemotherapy (see “Definitions”) and Radiation
Therapy (see “Definitions”).
34
Oral drugs purchased at a pharmacy are not covered under medical benefits. However,
they may be covered under the Plan’s prescription drug benefits (see “Chapter 7”)
•
Chiropractic Care, Physical Therapy, Occupational Therapy, Massage Therapy
and Acupuncture
Chiropractic, physical therapy, occupational therapy, massage therapy, and/or
acupuncture are covered by this Plan only if Medically Necessary and the practitioner is
licensed in the state.
If a person covered under the Plan has more than 30 visits within a calendar year, that
person will need to have any additional visits pre-certified to ensure appropriate medical
care. Please call CBA to pre-certify coverage before expenses are incurred for more than
30 visits within a calendar year. (Note: This 30-visit limit applies to a combination of all
types of visits for the same or unrelated conditions.)
•
Speech Therapy
The Plan will cover eligible charges for Speech Therapy (see “Definitions”).
•
Durable Medical Equipment
The Plan will cover eligible charges for Durable Medical Equipment (see “Definitions”).
•
Hearing Aids
Hearing aids must be necessitated by impairment of hearing following ear surgery or due
to traumatic injury. No benefit will be paid for replacement of a hearing aid for any
reason.
The Plan will pay a maximum up to $750 per ear in hearing aid charges in a covered
person’s lifetime.
•
Private Duty Nursing
The Plan will cover a maximum of $10,000 in eligible private duty nursing charges for
any covered individual in a calendar year. The following conditions must also be met:
o The patient cannot be in a Hospital or other institution that provides nursing
services;
o The services must be required to treat an acute illness or injury; and
o The nursing services must be provided by a registered graduate nurse and cannot
be provided by you, your spouse, or anyone related to you or your spouse by
blood or marriage.
This benefit covers professional nursing care for individuals whose health and welfare
would be endangered without the skill and training of a registered graduate nurse.
Benefits will not be paid for any services that are primarily Custodial Care and:
o Are mainly to assist the patient with the functions of daily living or to dispense
oral medication; and
o Could be properly furnished by someone who does not have the professional
qualifications of a registered graduate nurse.
•
Home Health Care Agency Benefits
35
There are limits to what the Plan will pay in charges made by a Home Health Care
Agency (see “Definitions”):
o Benefits will be paid for not more than 100 visits in a calendar year that are
furnished directly to a person during Home Health Care Agency visits. A visit of
four hours or less is counted as one visit. If a visit exceeds four hours, each four
hours or fraction thereof is counted as a separate visit; and
o For other services and supplies, the benefit will not exceed the amount that
would have been paid had they been furnished by a Hospital during an inpatient
confinement. For this purpose, a Hospital Confinement is considered a
continuous period during which inpatient care in a Hospital, Convalescent
Nursing Home or skilled nursing facility would be required were it not for the
home care.
Keep in mind: The Plan does not cover services:
o Rendered by you or your spouse, or someone related to you or your spouse by
blood or marriage;
o Provided by home health aides; or
o That are Custodial Care.
•
Miscellaneous Benefits
The Plan also provides benefits for several miscellaneous medical treatments, services
and supplies as follows:
o Blood and blood plasma not replaced by or for the patient;
o Medical devices such as artificial limbs, eyes and larynx; electronic heart
pacemaker; surgical dressings, casts, splints, trusses, braces, crutches, oxygen and
rental of equipment for its administration;
o Contact lenses and eyeglasses necessitated by and obtained immediately
following a cataract operation, but not to exceed the R&C limits, provided that
no benefit will be payable unless Medically Necessary. No benefits will be paid
for replacement of contact lenses or eyeglasses due to loss, breakage or
prescription change; and
o Coverage for implantable contraceptive devices, as well as insertion of the
devices. However, the Plan does not cover the removal of the implantable
contraceptive unless Medically Necessary.
Clinical Policy Bulletins
The Plan uses Clinical Policy Bulletins (CPBs) as a guide when making certain clinical
determinations about health care coverage. CPBs are written on selected clinical issues, especially
addressing new technologies, new treatment approaches, and procedures. Based upon a review
of currently available clinical information, the CPBs discuss whether certain procedures, services
or supplies are Medically Necessary, experimental and investigational, or Cosmetic Procedures,
as defined by the Plan. CPBs are intended solely to assist in administering plan benefits, and are
not intended to constitute a description of plan benefits. CPBs are regularly updated and are
therefore subject to change, with or without notice, to be effective at any time. Because CPBs
can be technical, the Plan encourages participants to review the CPBs with their providers. CPBs
can be found on the NRECA Employee Benefits website via Cooperative.com. The issues
36
addressed by the CPBs include, but are not limited to, the clinical issues listed below. Additional
CPBs may be added at any time.
BRCA Testing
BRCA Testing (molecular susceptibility testing for breast and/or ovarian cancer) is covered
under the Plan if Medically Necessary and you satisfy the standards of the applicable CPB.
Diabetes Self-Care
Diabetes Self-Care is covered under the Plan if Medically Necessary and you satisfy the standards
of the applicable CPB.
External Insulin Infusion Pumps for Type 1 Diabetes
External Insulin Infusion Pumps for Type 1 Diabetes are covered under the Plan if Medically
Necessary and you satisfy the standards of the applicable CPB.
Keratoconus and Medical Plan Coverage of Contact Lenses
The Plan excludes coverage of contact lenses for participants diagnosed with Keratoconus.
Medically Necessary Nutrition Counseling
The Plan covers nutrition counseling for a defined set of chronic diseases if Medically Necessary
and satisfying the standards of the applicable CPB.
Prophylactic Mastectomy
Prophylactic Mastectomy for the reduction of breast cancer risk is covered under the Plan if
Medically Necessary and certain risk factors exist as defined in the CPB.
Spinal Arthroscopy
Spinal Arthroscopy is covered under the Plan if Medically Necessary and you satisfy the
standards of the applicable CPB.
Treatment of Complications from Non-Covered Procedures
Treatment of Complications from Non-Covered Procedures is covered under the Plan if
Medically Necessary and you satisfy the standards of the applicable CPB.
Please consult the NRECA Employee Benefits website for more information.
Coverage While Traveling Outside the United States
In order for a service obtained outside the United States to be covered under the Plan, the
information provided to the Plan must include the following:
•
The service must be a recognized service in the United States;
•
All provider billings and/or records must be translated into English;
•
Bills must clearly show the patient’s name, provider’s name, date of service, diagnosis
and a description of the services rendered; and
•
The current money exchange rate needs to be provided with the bill showing the daily
rate for the dates the services were rendered. (Helpful hint: if the patient uses a credit
card, the card service will automatically translate the expenses into the United States
currency rate.)
37
Benefits for covered services received outside of the United States will always be paid to the
participant. Please keep in mind that the participant will be required to pay for all services up
front before submitting charges to the Plan.
WebMD Health Manager
Effective March 1, 2012, WebMD Health Manager is an interactive, online portal that provides
you and your dependents, at least 18 years of age, with access to the information you need to
make better choices about your health. The site includes a variety of resources and easy-to-use
tools developed by one of the most trusted sources of health and medical information. However,
medical decisions are ultimately made by you and your Physician, and do not involve the Plan.
Through WebMD Health Manager, users can access critical information about preventing or
managing serious diseases, locate Physicians and Hospitals in the area, watch videos and browse
recipes, develop personalized health improvement plans and more.
Key features:
•
Symptom Checker helps you determine if and when you should seek medical treatment.
•
Health Topics give you current, reliable information about specific health conditions
you may be interested in.
•
Health Trackers allow you to chart your progress toward achieving specific health goals
such as weight loss, physical activity and stress management.
To access WebMD Health Manager:
•
Log on to www.cooperative.com
•
Click on My Benefits
•
Click on WebMD in the top navigation bar
•
Complete the one-time WebMD Health Manager registration
MyHealth Coaches
WebMD Health Manager also provides access to MyHealth Coaches via The Dialog CenterSM.
MyHealth Coaches are specially trained health professionals (such as nurses, dietitians and
respiratory therapists) available for you to call any hour of the day or night to answer questions
and address any concerns about your health condition. You can contact a MyHealth Coach 24
hours a day, seven days a week at 1.866.696.7322. MyHealth Coaches specialize in working with
people living with chronic conditions, including: asthma, diabetes, coronary artery disease,
chronic obstructive pulmonary disease and congestive heart failure. All conversations with your
MyHealth Coach will be confidential and private. You can also send a secure message through
The Dialog CenterSM to a MyHealth Coach. A confidential reply will arrive in your inbox within
24 hours to help direct you to the information you seek.
In addition to contacting a MyHealth Coach, The Dialog Center provides valuable tools,
information and resources to support many different health care needs. It also features
Healthwise Knowledgebase®, an online encyclopedia of medical information, and Health
Crossroads Web ModulesSM , which include decision support, treatment options and prevention
tips about major medical conditions. Shared Decision Making Programs® (available on DVD)
contain unbiased information organized around Preference Sensitive Decisions, which are any
medical decisions where your values, preferences and lifestyle should be considered when
treatment options are evaluated with your Physician. A MyHealth Coach can tell you if a
particular program is right for you.
38
Tobacco Cessation Program
Studies show that tobacco users have a better chance of successfully quitting when they
participate in a counseling program. Your plan makes a program like this available to you and
your covered dependents ages 18 and older through MyHealth Coaches. The program is
designed to help individuals quit using tobacco, including smoking and smokeless tobacco use.
The program provides telephone counseling support and mailed materials. Contact MyHealth
Coaches 24 hours a day, seven days a week at 1.866.696.7322.
Program participants who are smokers, are eligible to receive either free Nicotine Replacement
Therapy (NRT) (e.g., patch, gum, lozenge) mailed directly to them (if medically appropriate), or
coverage for the tobacco cessation prescription medications, Chantix or Zyban, which are
otherwise not covered by the Plan’s prescription drug benefits. Program participants who are
chewers are not eligible for prescription medications because tobacco cessation prescription
drugs are not approved by the Food and Drug Administration (FDA) for use with chew tobacco.
Charges Excluded Under the Plan
Blood Charges
The Plan will not cover charges for blood or blood plasma that is replaced by or for the patient.
Charges for Unnecessary Services and Supplies
The Plan will not cover charges for services and supplies – including tests or check-up exams –
that are not Medically Necessary. Charges for Cosmetic Procedures are excluded by the Plan.
Dental Expenses
The Plan will not cover dental expenses, including charges for Physician’s services or x-ray
exams involving one or more teeth, the tissue, or structure around them, or the gums.
This exclusion of dental expenses applies even if a condition requiring any of these services
involves a part of the body other than the mouth such as the treatment of Temporomandibular
Joint Disorders (TMJD) or malocclusion involving joints or muscles by methods including but
not limited to, crowning, wiring, or repositioning teeth.
However, this exclusion does not apply to charges for:
•
TMJD when the Plan determines that internal derangement and degeneration exists, that
treatment is appropriate for the existing condition, that a suitable long-term prognosis
can be achieved by this treatment, and that there is no alternative treatment that is less
irreversible and/or less invasive;
•
Treatments by a Physician, dentist, or dental surgeon of injuries (excluding injuries as a
result of chewing) to sound natural teeth including replacement of such teeth, and related
x-rays received within 12 months after an Accident;
•
Removal of unerupted impacted teeth or of a tumor or cyst, or incision and drainage of
an abscess or cyst; or
•
Charges for extraction of seven or more teeth at the same time.
Eye Care Charges
Eye care charges (such as radial keratotomy or similar procedures such as LASIK) not
specifically outlined in the Plan will not be covered by the Plan.
Foot Condition Charges
39
The Plan will not cover charges for Physicians’ services in connection with weak, strained, or flat
feet, any instability or imbalance of the foot, or any metatarsalgia or bunion, unless the charges
are for an open cutting operation that is otherwise covered. Further, the Plan will not cover
charges in connection with corns, calluses, or toenails unless the charges are for the partial or
complete removal of nail roots, or the services are reasonably necessary in the treatment of a
metabolic or peripheral-vascular disease.
Government Plan Charges
In most cases, the Plan will not cover charges for a service or supply that is furnished under any
government program. Contact CBA for more information.
Impregnation or Fertilization Charges
The Plan will not cover charges related to or for actual or attempted impregnation or fertilization
that involves either a covered person or a surrogate as a donor or recipient.
Manipulation Therapy Charges
The Plan will not cover charges incurred in connection with treatment of a chronic maintenance
condition by manipulation therapy.
Occupational Injury or Disease Charges
In most cases, the Plan will not cover charges incurred in connection with the following:
•
Injury that arises out of, or in the course of, any employment for wage or profit; or
•
Sickness that is covered by any workers’ compensation law, occupational disease law or
similar legislation.
Charges incurred that would be excluded under the above items may be paid by CBA, at its
discretion, if:
•
Payment has not been made;
•
There is a dispute between the participant and the party responsible for payment of
occupational injury and disease charges as to whether the charges are payable or
regarding the amount that should be paid; and
•
The participant involved (or if incapable, a legal representative) agrees in writing on
forms provided by CBA, to pay back the benefits advanced at a rate of prime plus 3%
interest rate, as a result of injury or sickness to the extent of any future payments made
by or on behalf of the party responsible for occupational injury or disease within 30 days
of receipt of payment.
Prescription Drugs and Diabetic Supplies
Outpatient prescription and non-prescription drugs are not covered under the medical benefit
services of the Plan. Prescriptions for outpatient prescription drugs should be filled through CVS
Caremark (see “Chapter 6”).
Diabetic Supplies are no longer covered under the medical benefit services of the Plan. These
supplies may be obtained through CVS Caremark (see “Chapter 6”).
Sterilization Reversal Charges
The Plan will not cover charges incurred in connection with a surgical procedure to reverse a
vasectomy or a sterilization tubal ligation.
40
General Exclusions
In addition, Plan benefits for services or supplies are not eligible under this Plan if:
•
•
•
•
•
•
•
•
•
•
Charges are covered under another benefit plan for which your employer pays all or part
of the cost.
Charges are for services that are not needed for yourself or a dependent.
Charges are for a supply your employer is required to furnish.
Charges are for the treatment of injury or illness incurred as a result of declared or
undeclared war, an act of war, or resistance to armed aggression.
Charges are for the treatment of injury or illness incurred in the commission of an
assault, felony, strike, civil disorder, or riot. However, this exclusion does not apply to
otherwise eligible charges for the treatment of injury or illness incurred by victims of
domestic violence.
Charges are for treatment of injury or illness incurred while you are confined to jail,
prison, or other house of correction as a result of conviction for a criminal or other
public offense.
Charges are those which the covered person otherwise would not have the responsibility
to pay. For example, for coordination of benefit purposes, this Plan – as the secondary
plan – will not cover charges that have been denied by the primary plan and for which
the patient is not responsible.
Charges for the claim and all supporting materials for those charges are received more
than 24 months after the services or supplies are provided.
Charges are higher than R&C Rates.
Charges are for services rendered by yourself, or by anyone related to you or your
dependents by blood or marriage.
Coordinating Benefits with Other Plans
This Plan contains a coordination of benefits provision that applies whenever an allowable
expense under this Plan is also covered under one or more other plans. Under the general
coordination of benefits rule, the total benefits that will be paid will not exceed 100% of the
allowable expenses. “Other plans” include:
•
Other group plans, whether insured by insurance or self insured;
•
Governmental plans (except Medicaid); and
•
Medical insurance as provided by a motor vehicle insurance contract.
An allowable expense is any necessary expense covered, at least in part, by one of the plans of
the same type.
Primary and Secondary Plans
When a claim is made, the primary plan pays its benefits without regard to any other plans. The
secondary plans adjust their benefits so that the total benefits available will not exceed the
allowable expenses. No plan pays more than it would without the coordination provision.
A plan without a coordination of benefits provision similar to this Plan’s provision is always the
primary plan. If all plans have such a provision, to determine which plan is primary, the
following rules apply, in the order in which they are presented:
41
•
Employee/dependent: The plan covering an individual, other than as a dependent, is
primary to the plan covering an individual as a dependent.
•
Dependent child/parents not separated or divorced: The plan of the parent whose
birthday falls earlier in the year will be primary. (If both parents have the same birthday,
the plan that has covered the parent the longest is primary).
•
Dependent child/parents separated or divorced: The plans of the parents pay in this
order:
o If a court decree has established financial responsibility for the child's health care
expenses, the plan of the parent with this responsibility.
o The plan of the parent with custody of the child.
o The plan of the stepparent married to the parent with custody of the child.
o The plan of the parent not having custody of the child.
•
Active/inactive: The plan covering an individual through active employment is primary
to the plan covering the individual through retirement or layoff status.
•
Longer/shorter length of coverage: If none of the above applies, the plan covering
the individual for the longest period is primary.
When this Plan is providing secondary coverage, this Plan’s benefit is adjusted, taking into
account the primary plan’s payment and excluding any charges that have been disallowed by the
primary plan and for which the patient is not responsible, so that the total benefits available
under both plans will not exceed the allowable expenses. This Plan never pays more than it
would have paid without the coordination provision.
To receive payment on a claim when this Plan is secondary, you must submit an Explanation of
Benefits (EOB) from the primary plan and attach it to the itemized bill.
Coordination With Medicare
If you and any of your covered dependents are eligible for Medicare benefits, the benefits
payable under this Plan will be coordinated with the benefits payable under Medicare. In some
cases, this Plan will be the primary plan and will pay benefits without regard to your Medicare
benefits. In other cases, this Plan will be the secondary plan and your benefits under the Plan
will be reduced by your Medicare benefits. Here’s how to determine if your NRECA Plan is
primary or secondary:
•
Your NRECA Plan is the primary plan (and Medicare is secondary) if you are actively at
work (for example, if you have not yet retired), if you are disabled and have not yet
qualified for Medicare coverage, or during the first 30 months of your Medicare coverage
for kidney dialysis treatment or a kidney transplant.
•
Your NRECA Plan is the secondary plan (and Medicare is primary) if you are 65 and
older and not actively at work (for example, if you are retired), if you are disabled and
have qualified for Medicare coverage, or after the first 30 months of your Medicare
coverage for kidney dialysis treatment or a kidney transplant.
When your NRECA Plan is the primary plan, your benefits will be determined independently of
any Medicare benefits you may receive. When Medicare is primary, the medical benefits under
your NRECA Plan are reduced by the Medicare benefits available under Medicare Parts A and B,
whether or not you have enrolled in both programs. The specific amount of the reduction will be
determined by CBA and reflected on your EOB. If you anticipate that Medicare will be your
primary plan, you should apply for full Medicare coverage under Medicare Parts A and B to
42
ensure that you receive the maximum combined benefits available under Medicare and the
NRECA Plan.
Occasionally, you or your dependents may have coverage under the NRECA Plan, Medicare and
a third plan, such as when you are covered as a dependent under a plan sponsored by your
spouse’s employer. In this case, the benefits payable under your NRECA Plan will be determined
by applying these Medicare coordination rules first, and then applying the rules discussed on the
previous page.
Chapter 5:
Medical Claims and Appeals
Claims and Appeals Procedures
Internal and external claims and appeals processes are available under this Plan.
Keep in mind: You must meet the requirements of the internal appeals process before pursuing
the external appeals process, unless you are experiencing a Medical Emergency or life threatening
event.
Remember: You and your dependents must call SHARE to pre-certify a non-emergency
Hospital admission. If you have been admitted to the Hospital for an emergency,
SHARE must be called within 2 business days of admission.
Pre-certification through SHARE is also required for all outpatient, non-emergency CTs
and MRIs of the spine and extremities.
If you fail to call SHARE for precertification under these circumstances, expenses
counted as eligible expenses will be reduced by 20%.
Claim Forms
If your health care provider does not submit the claim on your behalf, please submit your claim
to the address located on the back of your medical ID card. Claim forms are available on the
NRECA Employee Benefits Web site. Log on to www.Cooperative.com and click the Take Me
To My NRECA Employee Benefits button. Next, log on to NRECA Employee Benefits and
click on Library/Documents for Employees/Insurance Plans. Under the Medical Plans list, you
will find the Health Benefit Request Form. Ask your Benefits Administrator if you need help
obtaining a claim form.
If you plan to accumulate medical bills and submit them at a later date, keep a separate record of
the medical expenses. This will help you when you are ready to make a claim. Save all medical
bills. In most instances, they will serve as evidence of your claim. Accumulated medical bills
should show all of the following information:
•
Patient’s full name;
•
Date or dates the service was rendered or purchase was made;
•
Nature of the sickness or injury;
•
Type of service or supply furnished; and
43
•
Itemized charges.
All medical claims relating to payment for a benefit covered by the Plan must be filed no later
than 24 months from the date the service was rendered. A claim form will not be considered
filed until all required information related to the service or benefit for the claim has been
provided to CBA. Claims filed after 24 months from the date the service was rendered will not
be paid.
Authorized Representative
You may file claims for Plan benefits and appeal adverse claim decisions, either yourself or
through an authorized representative. An authorized representative is a person you authorize in
writing to act on your behalf. You also may provide CBA your written authorization to have a
Physician or other health provider request appeals of benefit denials on your behalf.
Designating an Authorized Representative
If you use an authorized representative, you will need to complete the form “Authorization to
Use and Disclose Protected Health Information”. Ask your Benefits Administrator for the
form. Before you submit the form to NRECA, you may contact the Plan’s Privacy Officer to
ask questions about the use and disclosure of your health information. You may contact the
Privacy Officer by telephone at (703) 907-6601, by fax at (703) 907-6602, or by email at
[email protected]. Please send the completed form to the Plan’s Privacy Officer at the
following address to be reviewed and accepted:
Privacy Officer
NRECA
4301 Wilson Boulevard
Arlington, VA 22203-1860
The Plan will provide you with a copy of the signed Authorization form for your records.
There are specific claim and appeal response periods for your claims.
Internal Process for Medical Claims and Appeals
There are four different types of claims under the Plan:
•
Pre-Service Claim – any claim for benefits for which the Plan conditions receipt of the
benefit, in whole or in part, on approval of the benefit in advance of obtaining care
under the Plan – unless the claim involves urgent care, as defined below. An example is
precertification through SHARE for an inpatient Hospital stay.
•
Post-Service Claim – any claim for benefits for services or supplies already rendered.
An example is a doctor’s exam that has already been performed.
•
Concurrent Care Claim – any claim for benefits for an ongoing course of treatment to
be provided over a period of time or for a specified number of treatments.
•
Urgent Care Claim – any claim for benefits involving urgent care or treatment with
respect to life or health or the ability to regain maximum function, or severe pain that
cannot adequately be managed without urgent care or treatment.
The table on the following pages explains the internal process for filing claims and appeals.
INTERNAL PROCESS FOR FILING MEDICAL CLAIMS AND APPEALS
44
PRE-SERVICE
CLAIMS
File claim
before or after
treatment:
Submit your
claim to:
Date your
claim is
considered
“filed”:
Time Period
that CBA has
to notify you
that your claim
is approved or
denied:
Before
POSTSERVICE
CLAIMS
CONCURRENT
CLAIMS
URGENT
CARE
CLAIMS
After, but not
later than 24
months from
the date the
service was
rendered.
After, but not later
than 24 months
from the date the
service was
rendered.
After, but not
later than 24
months from
the date the
service was
rendered.
Claims Administrator
CBA
P.O. Box 6249
Lincoln, NE 68506
The date CBA receives your completed claim in writing.
Not later than 15
days from the date
CBA receives your
claim. CBA may
require one 15-day
extension if
circumstances
warrant additional
time. CBA will notify
you of the extension
before the initial 15day period is up.
Not later than
30 days from
the date CBA
receives your
claim. CBA
may require
one 15-day
extension if
circumstances
warrant
additional
time, and will
If CBA needs the 15- notify you
day extension because that it needs
more time to
you did not provide
evaluate your
all the information
claim. CBA
needed to process
your claim, CBA will will notify you
of the
tell you what
extension
information is
before the
missing.
initial 30-day
period is up.
If CBA needs
the 15-day
extension
because you
did not
provide all the
information
needed to
45
Not later than 24
hours if treatment
involves an
extension of
urgent care and
the request is
made within 24
hours of end of
period or number
of treatments.
If you do not
provide all the
information
needed to process
your claim, CBA
must notify you of
what information
is missing within
24 hours of receipt
of the claim.
If the claim does
not involve urgent
care, then same as
pre-service or
post-service time
periods, as
applicable.
Not later than
72 hours from
the date CBA
receives your
claim.
If you do not
provide all the
information
needed to
process your
claim, CBA
must notify
you of what
information is
missing within
24 hours of
receipt of the
claim.
PRE-SERVICE
CLAIMS
POSTSERVICE
CLAIMS
CONCURRENT
CLAIMS
URGENT
CARE
CLAIMS
process your
claim, CBA
will tell you
what
information is
missing.
If your claim is
incomplete, the
time period
you have to
submit
additional
requested
information to
CBA:
The period of
time CBA has to
decide your claim
once you submit
additional
requested
information:
If your claim is
denied:
Time period
that you, or
Not later than 45 days from the date CBA sends you
the notice to tell you that your claim is missing
information. The time period for deciding your
claim is suspended from the date CBA notifies you
that the claim is incomplete until the date you
provide the missing information.
48 hours
If you do not send CBA the missing information
within this 45-day period, CBA will deny your claim.
15 days
Remainder of
time available
in initial claim
review period.
Remainder of time
available in initial
claim review
period.
Within 24
hours after the
earlier of 1)
receiving
requested
information or
2) the
expiration of
the time
period to
produce the
information.
CBA will provide you a notice that contains:
•
Specific reason(s) for the benefit denial;
•
Reference to specific Plan provisions on which denial is based;
•
Description of any additional information needed to perfect the claim,
and an explanation of why such information is needed;
•
Description of the Plan’s review procedures and time limits that apply
to them;
•
Explanation of your rights under ERISA’s claim and appeals rules;
and
•
A copy of any internal rule, guideline, protocol or similar criterion
relied on (or a statement that the material is available upon request for
free).
Not later than 180 days from the date you receive the notice that your claim is
46
PRE-SERVICE
CLAIMS
POSTSERVICE
CLAIMS
CONCURRENT
CLAIMS
URGENT
CARE
CLAIMS
denied.
your
authorized
representative,
have to request
an appeal:
You may request copies of all documents, records, and other information related to your
denied claim from the Plan, free of charge. You also have the right to submit with your
appeal written comments, records, documents and other information to support your
appeal, whether or not you already submitted these items.
Appeals Administrator
CBA
P.O. Box 6249
Lincoln, NE 68506
The Appeals Administrator is a different person than the person who made the original
decision to deny your claim and is not someone directly supervised by the original
decision-maker. The Appeals Administrator will conduct a full and fair review of all
documents and evidence to support your claim for benefits and may consult with experts
in order to make a decision about your appeal. These experts are different from the ones
previously consulted.
Submit your
Appeal to:
Time Period
the Appeals
Administrator
has to review
your appeal
and make a
decision:
Not later than 30
days from the date
the Appeals
Administrator
receives your appeal.
Not later than
60 days from
the date the
Appeals
Administrator
receives your
appeal.
Same as urgent
care or pre-service
appeals, as
applicable.
Not later than
72 hours from
the date the
Appeals
Administrator
receives your
appeal.
If your appeal
is denied:
The Appeals Administrator will provide you a notice that contains:
•
Specific reason(s) for the benefit denial;
•
Reference to specific Plan provisions on which denial is based;
•
Explanation of your rights under ERISA’s claims and appeals rules;
and
•
A copy of any internal rule, guideline, protocol or similar criterion
relied on (or a statement that the material is available upon request for
free).
You have now completed the Plan’s internal appeal process. You may request an
External Review, or you may seek legal action under ERISA within 12 months from the
date of this appeal.
47
External Review Process for Claims Denials and Coverage Rescissions
You have the right to request an external review of a final claims denial or coverage rescission
(adverse benefit determination) within four (4) months of receipt of such notice for medical and
prescription drug claims.
The external review will be conducted by an independent review organization (IRO) with which
the Plan has contracted to ensure an independent and unbiased review of your adverse benefit
determination – a “fresh look”. The IRO’s decision to approve a claim is binding on the Plan.
Upon receipt of your request for External Review, the Plan shall conduct a preliminary review
within five (5) business days to determine if the adverse benefit determination is eligible for
external review. The adverse benefit determination is eligible for external review if:
•
•
•
•
you are or were covered under the Plan at the time the claim was incurred;
the adverse benefit determination involves medical judgment;
you have exhausted the Plan’s internal appeal process; and
you have provided all the information and forms required to process the external review.
Within 1 business day after completion of the preliminary review, the Plan shall notify you that
your request for external review:
•
•
•
is acceptable in its current form, in which case the request will be referred to the IRO;
is incomplete, in which case you will have 48 hours (or 4 months from the final notice of
adverse benefit determination, if later) to provide additional materials; or
is complete but not eligible for External Review, in which case the Plan will notify you of
the reasons for its ineligibility and provide the contact information for the U.S.
Department of Labor’s Employee Benefits Security Administration.
If the request is referred to the IRO, such IRO’s decision will be provided within 45 days of
receipt, and will be binding on the Plan.
In addition to any documents you provide to the IRO, the IRO will consider the following items
in reaching its decision:
•
•
•
•
•
•
•
Your medical records;
Recommendation of the attending health care professional;
Reports from appropriate health care professionals and other documents submitted by
the Plan, you, or your treating provider;
The governing plan terms in the Plan document;
Appropriate practice guidelines, which must include applicable evidence-based standards;
Any applicable clinical review criteria developed and used by the Plan; and
The opinion of the IRO’s clinical reviewer(s).
CBA will provide you, free of charge, a copy of any new or additional evidence considered, relied
upon, or generated by the Plan in relation to the claim during the appeals process.
Below is a list of key steps and deadlines:
48
EXTERNAL REVIEW STEP
DEADLINE
You request an external review with CBA.
Within 4 months following receipt of a final
notice of benefits denial or coverage
rescission.
Submit your claim to:
Appeals Committee
Cooperative Benefit
Administrators, Inc.
External 9222
P.O. Box 6249
Lincoln, NE 68506
For a prescription drug external review,
submit your request to:
CVS Caremark
External Review Appeals Department
MC 109
P.O. Box 52084
Phoenix, AZ 85072-2084
Fax Number: 1-866-689-3092
Plan’s preliminary review determination.
Within 5 business days following receipt of
external review request.
Plan’s notice to you regarding preliminary Within 1 business day after completion of
preliminary review.
review determination.
Your time period for perfecting an
incomplete external review request.
Remainder of 4-month filing period, or if
later, 48 hours following receipt of notice.
Written notice by IRO to you of
acceptance for review and deadline for
submissions of additional information.
In a “timely” manner. You will have 10
business days to submit additional
information that must be considered by
IRO.
Time period for Plan to provide IRO
documents and information considered in
making benefit determinations.
Within 5 business days of referral to IRO.
IRO forwards to the Plan any additional
information submitted by you to IRO.
Within 1 business day of receipt.
49
DEADLINE
Notice to you and IRO if Plan reverses its
adverse benefit determination
Within 1 business day of decision.
Decision by IRO
Within 45 days of receipt of request for
review.
Other resources to help you: For questions about your appeal rights, or for assistance, you can
contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272).
Expedited External Review Process
The Plan must permit you to request an expedited external review for medical and prescription
drug claims when you receive:
•
•
A benefits denial involving your medical condition where the timeframe for completing
an urgent appeal under the appeals regulations would seriously jeopardize your life or
health or your ability to regain maximum function and you have filed an urgent appeal
request; or
A final internal appeal denial involving your medical condition where the timeframe for
completing a standard external review would seriously jeopardize your life or health or
your ability for to regain maximum function and you have filed an urgent appeal request,
or an admission, availability of care, continued stay, or health care item or service for
which you received emergency services, but have not been discharged from a facility.
The review process is identical to the process described above in Section “External Review
Process for Claims Denials and Coverage Rescissions”.
Below is a list of key steps and deadlines:
Submit your claim to:
DEADLINE
Immediately
Appeals Committee
Cooperative Benefit
External 9222
P.O. Box 6249
Lincoln, NE 68506
1-866-673-2299 Option 1
Plan’s preliminary review determination.
Immediately upon receipt. The Plan must
assess whether the request meets the
reviewability requirements outlined in the
50
DEADLINE
External Review Process.
Plan’s notice to you regarding preliminary Immediately.
review determination
The decision must meet the requirements
that apply to the External Review Process.
The notice must be provided as
expeditiously as your medical condition or
circumstances require, but not more than 72
hours after the IRO receives the expedited
review request. If the notice is not in
writing within 48 hours after the date it
provides the non-written notice, the IRO
must provide written confirmation of the
decision to you and the Plan.
Decision by IRO
Chapter 6:
Prescription Drug Benefits
the Plan. Please read “Coverage Under Medicare” below.
Your prescription drug benefit is a key element of your health care benefits package under the
Plan. CVS Caremark is the Plan’s Pharmacy Benefit Manager.
How the Plan Works
You will be provided with a prescription ID card. This card is in addition to the Plan ID card
provided for your medical benefits under the Plan.
Keep these factors in mind so you can save money on the cost of prescription drugs:
•
You will pay the least amount for a prescription when you obtain a generic drug. So you
should choose a generic whenever possible;
•
For maintenance medications, you can order up to a 90-day supply of the prescription
through CVS Caremark. This will not only save you money, but it will save you trips to
the pharmacy, as the medication will be delivered right to your door; and
•
You will receive a CVS Caremark ExtraCare® Health Card which will enable you to
receive a 20% discount on regular, non-sale priced CVS Store Brand health-related items
and CVS Store Exclusive Brand health-related items of $1 or more. To receive the
discount, you should present the card at the time of purchase at Retail Network
Pharmacies. The CVS Caremark ExtraCare® Health Card also gives you all the benefits
of the current CVS ExtraCare® program.
51
Keep in mind: The Physician who prescribes the medication, the pharmacist who fills the
prescription, and the pharmacy where the prescription is filled must all be licensed in the United
States.
How To Fill a Prescription at Retail Pharmacy
You can receive up to a 30-day supply of the medication at retail pharmacy. Specialty/Biotech
drugs are not eligible for coverage through a retail pharmacy (see section “Specialty/Biotech
Drugs”).
How To Fill a Prescription through CVS Caremark Mail Service Pharmacy
All NRECA prescription drug benefit options have a mail-order pharmacy available, which has
three distinct cost saving advantages over retail pharmacies:
•
Participants can order up to a 90day supply. At a retail pharmacy, the most a participant
can order is a 30day supply;
•
Ingredient costs through mail-order are lower and drug discounts are greater than at a
retail pharmacy;
•
There is no dispensing fee, which lowers the prescription price. A dispensing fee is
charged at retail pharmacies.
By using this service for long-term maintenance drugs, you can save money.
You may obtain up to a 90-day supply of maintenance medications through the CVS Caremark
Mail Service Pharmacy. Maintenance medications are usually prescription drugs that are used on
an ongoing basis and are for the treatment of such illnesses as anemia, arthritis, diabetes,
emotional distress, emphysema, epilepsy, heart disorders, high blood pressure, thyroid or adrenal
conditions, or ulcers.
The CVS Caremark Mail Service Pharmacy provides a convenient and cost-effective way for you
to order up to a 90-day supply of maintenance or long-term medication for direct delivery to
your home. Mailing cost is included when drugs are obtained through the CVS Caremark Mail
Service Pharmacy, unless you specify a special method of shipping (e.g., UPS, FedEx, etc.), then
you will be responsible for the extra shipping charges.
If you take a maintenance medication, ask your Physician to write a prescription for 90 days with
three refills (total of one year). Complete the mail service order form and send it to CVS
Caremark with your original prescription. The preferred method of payment is by credit card.
You may elect to pay your prescription cost-sharing amount upon delivery of the drug mail order
and accompanying order invoice. However, to avoid potential order delays, or canceled orders,
participants are encouraged to pre-pay your cost-sharing amount when ordering from the CVS
Caremark Mail Service, whether ordering by phone, mail or the Internet. Pre-payment may be
made by personal check, money-order, bank card or credit card. CVS Caremark Mail Service
only permits an outstanding account balance of $200 maximum per family. If that limit is
exceeded, CVS Caremark will hold the order, and contact the participant requesting a payment
by bank or credit card before releasing the order.
You can expect to receive your prescription approximately 10-14 days after CVS Caremark
receives your order. You will receive a new pre-printed mail service order form and return
envelope with each shipment. You should use the pre-printed mail service order form verifying
that your name, identification number and mailing address are all correct. Send to the CVS
Caremark mailing address pre-printed on the form, which may be San Antonio, TX, Palatine, IL
or another CVS Caremark mail facility.
52
Once you have processed a prescription through CVS Caremark, you can obtain refills using the
Internet, the 24-hour phone service, or by mail:
•
Internet: Visit www.caremark.com to order prescription refills or inquire about the status
of your order. You will need to register on the site and log in.
•
Phone: Call 888-796-7322 for CVS Caremark’s fully automated refill phone service.
•
Mail: Attach the refill label provided with your prescription order to a mail service order
form. Enclose your payment and mail the order form to the pre-printed mailing address
on the form or CVS Caremark at P.O. Box 659529, San Antonio, TX 78265.
What the Plan Covers
Cost Sharing (Coinsurance)
For most prescription drug benefits, you and the Plan will share the cost of the prescription drug
expenses once your deductible is satisfied. You will pay a percentage of the cost and the Plan will
pay the remaining percentage of the cost (see “Chapter 2”). This is called coinsurance. Once you
have satisfied your annual OOP coinsurance maximum, the Plan will pay 100%.
Keep in mind: You may pay less when you use the Retail Network Pharmacies (In-Network). If
you don’t use the Retail Network Pharmacies (Out-of-Network), you will be responsible for any
difference between what the cost would have been In-Network and the actual cost of the
prescription.
To find a Retail Network Pharmacy contact CVS Caremark (see “Chapter 1”).
Chronic Conditions
You will receive occasional mailings if you or your dependents have chronic conditions to help
you and your dependents use medications appropriately and improve the quality of your lives.
For example, diabetes-related mailings offer free blood glucose monitors and prescriptions for
test strips, subject to your coinsurance, to participants living with diabetes.
Diabetic Supplies
Diabetic Supplies include, but may not be limited to, Insulin, needles, clinitests, syringes, test
strips, alcohol swabs, lancets and select insulin pump supplies such as infusion sets, reservoir
tips, and Polyskin.
Prescription Drugs and Supplies Covered Under the Plan
Keep in mind: A new drug may be covered under the Plan when it receives FDA approval.
The new drug is still subject to the Plan exclusions (see “Drugs and Supplies Excluded Under
the Plan”). In general, if treatment of a particular condition is not covered under the Plan, then
drugs used for the purpose of treating that condition are also not covered.
Drugs and supplies frequently covered under the Plan include:
•
Acne medication such as Retin-A, Avita, Altinac (tretinoins) and Differin (adapalene) for
individuals 34 years of age and younger;
•
Aspirin, all oral forms, to include oral, chewable, delayed release and dispersible (includes
any strength 325mg or less). Limited to men and women 45 years of age and greater;
generic only is covered; and a prescription is required even though item may be available
over-the-counter (OTC);
•
DDAVP (desmopressin);
53
•
Diabetic supplies including lancets, testing agents, alcohol swabs and select insulin pump
supplies;
•
Disposable needles and syringes;
•
Folic acid, strengths 0.4 mg to 0.8mg, for women 55 years of age or less; limited to
quantity of 100 and generic form only covered; prescription required even though item
may be available OTC;
•
Insulin;
•
Iron supplements for infants one (1) year of age or less. Must be single ingredient (iron
only), not combination vitamins or minerals. Examples: Oral liquids to include Ferrous
Sulfate elixir, syrup, solution, drops, or suspension or brand name products such as
Feosol; brand or generic covered; prescription required, even though item may be
available OTC;
•
Migraine medications, such as Amerge, Axert, Frova, Imitrex, Maxalt, Migranal, Relpax,
Sumavel Dosepro, Treximet and Zomig (see “Prior Authorization Drug”);
•
Oral contraceptives and prescription contraceptive devices, including transdermal and
injectable forms;
•
Prenatal vitamins (by prescription only);
•
Prescription inhalation devices such as Aerochamber, Spinhaler and Inspirease;
•
RhoGam and WinRho;
•
Herpes Zoster Vaccine; and
•
Sodium Fluoride, oral forms, for children 6 years of age and under only. Must be single
ingredient medication, and includes oral, chewable, solution or drop forms, on
prescription only; brand or generic covered. Only sodium fluoride meds that require a
prescription are covered.
The following are also covered:
•
Compounded medications (at least one ingredient must be a covered medication
requiring a prescription);
•
Erectile dysfunction drugs (quantity limitations apply); and
•
Nail fungus drugs (e.g., Lamisil, Penlac).
Prior Authorization Drugs
Prior Authorization of prescription drugs or drug categories are required to ensure safe, effective
and appropriate use of prescription drugs. Some of the reasons for requiring a prior
authorization on a medication include, but are not limited to medications that are:
•
Subject to overuse or misuse;
•
Limited to a specific patient population;
•
Limited to a specific diagnosis or condition;
•
Subject to significant safety concerns;
•
High cost;
54
•
Subject to additional criteria requirements or documentation needed to approve
coverage; or
•
Subject to Plan quantity limitations and the Physician determines that a larger quantity is
needed.
When a drug is denied at a retail pharmacy due to a Prior Authorization requirement, the
pharmacist is provided, along with the claim denial from the Pharmacy Benefit Manager, a
message with the phone number needed by the prescriber to contact the appropriate Prior
Authorization Department.
Keep in mind: Specialty/Biotech drugs are not eligible for coverage through a retail pharmacy.
See the chart below for Prior Authorization Drugs BEFORE the drug can be dispensed at either
a retail pharmacy or CVS Caremark Mail Service Pharmacies along with the contact information
for the Prior Authorization Department:
DRUGS NEEDING PRIOR
AUTHORIZATION FROM
CBA NURSES UNIT
CALL - 866-673-2299
•
•
Biologicals such as Albumin Human,
Factor IX Complex, Factor VIII,
Factor VIIA, Recomb (BHK Cells),
Anti-inhibitor Coagulant Comp,
Dextran, Albumin Human/Sodium
Chloride, Hetastarch/NA Chlor
0.9%, Immune globulins
DRUGS NEEDING
PRIOR
AUTHORIZATION
FROM
CVS CAREMARK
PRIOR
AUTHORIZATION
TEAM CALL
CALL - 800-626-3046
DRUGS NEEDING
PRIOR
AUTHORIZATION
FROM
•
Crinone gel, Prochieve
gel. Only covered if
patient is already
pregnant.
•
•
Desoxyn, Dexedrine,
Dextrostat, all forms
dextroamphetamine
sulfate, and C-2 drugs
used to treat ADHD,
such as Concerta,
Metadate CD, metadate
ER, Methylin, Methylin
ER, Ritalin, Ritalin LA,
Ritalin-SR, Adderall (all
forms and generics) for
those 19 years of age
and older. If diagnosis is
written on prescription,
then CVS Caremark
Mail will process
without a Prior
Authorization required.
Specialty
Drugs/Biotech. A list
of specialty/biotech
drugs is located on
the NRECA website
at
www.cooperative.c
om
•
Synagis
Dietary (nutritional) Supplements
(may be approved for treating
transplant patients or patients on
renal dialysis)
•
Growth hormones
•
Migraine medications, such as
Amerge, Axert, Frova, Imitrex,
Maxalt, Migranal, Ralpax, Sumavel
Dosepro, Treximet and Zomig may
require Prior Authorization. Prior
Authorization requirements vary for
each medication and are based on
FDA dosaging recommendations.
Physicians and pharmacists will be
directed to contact Caremark
CustomerCare at 1-888-796-7322 if
•
Testosterone products
(i.e. Depo-Testosterone,
55
CVS CAREMARK
SPECIALTY
PHARMACY
CALL - 800-237-2767
prior authorization is required.
•
Obesity or weight loss drugs,
appetite suppressants and
anorexiants such as Xenical,
Phentermine, Meridia, Ionamin
•
Prescription Vitamins, minerals and
vitamin/mineral combinations for
transplant patients or patients on
renal dialysis
•
Retin-A, Avita, Altinac (tretinoins)
and Differin (adapalene) for
individuals 35 years of age or older
Testopel Pellets)
Specialty/Biotech Drugs
Keep in mind: All specialty/biotech drug prescriptions must be filled through the CVS
Caremark Specialty Pharmacy Mail Services (see “CVS Caremark Specialty Pharmacy Mail
Services”) in order to be covered under the Plan. Prescriptions that are filled through retail
pharmacies are not covered and will not be reimbursed by the Plan.
Specialty/biotech drugs are used to treat a variety of serious and complex medical conditions,
such as multiple sclerosis, certain cancers, growth hormone disorders, hemophilia, rheumatoid
arthritis, Crohn’s disease, cystic fibrosis and hepatitis C. These drugs are derived from biological
processes and are considered specialty drugs. Biotech drugs are generally single-source brand
name medications, meaning there is no generic equivalent available in the marketplace. Many are
administered via injection, rather than taken orally, and require special shipping, storage and
administration.
There is a 30-day maximum supply limit for the drugs Thalomid and Revlimid. The maximum
day supply on other specialty drugs may be determined by CVS Caremark upon clinical review
before being dispensed. Quantities may be limited to 30-day, 60-day, or the maximum 90-day
supply.
Drugs used to treat the following conditions will require clinical review to determine whether the
therapy is appropriate and whether up to a 90-day supply may be dispensed at one time. They
also may require ongoing review in order to continue therapy.
•
Allergic Asthma
•
Growth Hormone Deficiency
•
Hepatitis C
•
Psoriasis
•
Rheumatoid Arthritis
•
Respiratory Syncytial Virus (RSV)
The CVS Caremark Specialty Pharmacy service helps participants use these drugs safely and
effectively adhere to the challenging treatment regimens associated with taking a specialty
56
medication. You will have access to educational materials, phone consultation and refill
reminders to help them with their specific treatments. CVS Caremark's Specialty Pharmacy
Services include programs related to:
•
Allergic Asthma
•
Cancer
•
Crohn’s Disease
•
Enzyme Replacement for Lysosomal Storage Disorders
•
Growth Hormone Disorders
•
Hematopoiesis Disorders
•
Hemophilia and von Willebrand Disease
•
Hepatitis C
•
Immune Disorders
•
Multiple Sclerosis
•
Psoriasis
•
Pulmonary Arterial Hypertension (PAH)
•
Pulmonary Disorders
•
Respiratory Syncytial Virus (RSV)
•
Rheumatoid Arthritis
CVS Caremark Specialty Pharmacy Mail Services
CVS Caremark Specialty Pharmacy Mail Services is required for all specialty/biotech drug
prescriptions.
You or your dependents must enroll to use CVS Caremark Specialty Mail Pharmacy Services to
fill and refill you biotech/specialty drug prescriptions. You can do so by calling
CaremarkConnect® at 1.800.237.2767 or online through www.caremark.com.
Once the requested information has been provided, a CareTeam specialist will contact your or
your dependent’s Physician to get the required prescription. The specialist will work with you,
your Physician and the Plan to confirm coverage and to conduct a clinical review of the
medicines the participant may need. Once enrolled with the pharmacy, participants can submit
or refill prescriptions online, by phone or by mail.
Please note: you can call CVS Caremark Connect® to transfer your biotech/specialty drug
prescription from your retail pharmacy to CVS Caremark Specialty Pharmacy Services.
Prescription Drug Support Online
The CVS Caremark web site allows you and your dependents to review your prescription drug
benefits, cost sharing and benefit coverage, general health and drug information as well as gives
you the ability to order refills for mail-order prescriptions. You also can check your personal
prescription history. You can even set up an email alert, which will prompt you when it is time
to refill your prescription. All personal and prescription drug information is password protected.
57
Pharmacy Clinical Support
Pharmacy Clinical Support, also known as cost containment, is part of the Plan. Pharmacy
Clinical Support adds another level of quality review to prescriptions by encouraging drug
therapy compliance and proper use of the prescription drug benefit, and helps in managing costs.
Under this program, CVS Caremark reviews prescription claims and, in some cases, contacts the
prescribing Physician to suggest drug therapy changes based on national clinical guidelines and
standards of care. The Physician decides if he or she will follow the recommendations and
approve the suggested changes.
An example of an intervention that occurs is the review of medications that are prescribed for a
longer duration of time than is recommended for certain drug classes such as muscle relaxants
and gastrointestinal (GI) medications (e.g., Nexium, Aciphex and Omeprazole). Refills of these
medications that are deemed excessive may be removed from a prescription if agreed to by your
Physician.
Every effort is made to ensure minimal disruption to you and your dependents. If you disagree
with a Physician-approved change, you can request to have the refills reinstated by having your
medical provider call 1.888.796.7322.
If changes are made to prescriptions filled through the mail-order service, you or your
dependents will receive a letter notifying you of the change along with the filled order. When
using the mail-order service, a short delay may occur while CVS Caremark attempts to contact
your Physician to discuss potential changes.
For retail prescriptions, this program reviews pharmacy claims after they are filled and
communicates recommendations and/or concerns to Physicians who will decide whether or not
to take CVS Caremark’s recommendation on your future prescriptions.
Drug and Supplies Excluded Under the Plan
The following list of drugs is not covered under the prescription drug benefit portion of the
Plan:
•
Allergy serums
•
Anabolic steroids
•
Biotech Drugs purchased outside of CVS Caremark Specialty Mail Services
•
Blood or plasma
•
Charges for the administration or injection of any drug
•
Dietary (nutritional) supplements such as Ensure, Limbrel and Vanachol or specialized
infant formula (see “Prior Authorization Drugs”)
•
Drugs administered in and billed by Physicians’ offices
•
Drugs available through public health programs
•
Drugs purchased outside of the United States
•
Drugs that do not require a prescription (over-the-counter drugs unless listed on the
covered drug list see “Prescription Drugs and Supplies Covered Under the Plan”)
•
Drugs which are taken or administered to a patient while he/she is a patient in a
Hospital, nursing home, extended care facility or similar institution which operates a
pharmacy on its premises
58
•
Growth hormones without prior authorization (see “Prior Authorization Drugs”)
•
Immunization agents and biological sera (drugs which are obtained, purified, and
standardized from human serum or plasma); and immune globulins without prior
authorization (see “Prior Authorization Drugs”)
•
Infertility drugs
•
Insulin pumps, blood glucose monitors unless covered under Chapter 4
•
Investigational or experimental drugs
•
Non-prescription vitamins and minerals
•
Obesity or weight loss drugs, appetite suppressants and anorexiants such as Xenical,
Phentermine, Meridia and Ionamin without prior authorization (see “Prior Authorization
Drugs”)
•
Ostomy supplies unless covered under Chapter 4
•
Prescription vitamins (except prenatal vitamins) and minerals (see “Prior Authorization
Drugs”)
•
Renova, Avage
•
Respigam
•
Retin-A, Avita, Altinac (tretinoins) and Differin (adapalene) for individuals 35 years of
age or older without prior authorization (see “ Prior Authorization Drugs”)
•
Specialty Drugs purchased outside of CVS Caremark Specialty Mail Services
•
Synagis without prior authorization (see “Prior Authorization Drugs”)
•
Testosterone products (i.e. Depo-Testosterone, Testopel Pellets without prior
authorization (see “Prior Authorization Drugs”)
•
Therapeutic devices or appliances, support garments and other non-medical substances
•
Tobacco cessation drugs, including Chantix, Zyban (bupropion SR 150mg), Nicotrol
inhaler or Nicotrol spray unless covered under Chapter 4
•
Topical fluoride preparations
•
Topical Minoxidil (such as Rogaine)
•
Vaccines unless covered under Chapter 4
Coverage Under Medicare
Retirees and their dependents for whom Medicare is the primary insurer will no longer be
covered under the prescription drug benefit of the Plan. Such retirees and their dependents may
enroll in the NRECA Medicare Part D Prescription Drug Plan or another creditable plan.
In addition, disabled participants and their dependents for whom Medicare is the primary insurer
(or participants with end-stage rental disease) will no longer be covered under the prescription
drug benefit of the Plan if the participant:
•
has been totally disabled for at least 6 months;
•
is not currently working; and
59
•
is receiving disability payments from their co-op beyond the first 6 months of disability.
Such disabled participants and their dependents may enroll in the NRECA Medicare Part D
Prescription Drug Plan or another creditable plan.
This section does not apply to participants due to end-stage renal disease (ESRD). Participants
with ESRD will remain covered under the prescription drug benefit of the Plan for the first 30
months of ESRD disability. After 30 months of ESRD disability, when Medicare becomes the
primary insurer, the participant will no longer be covered under the prescription drug benefit of
the Plan and must enroll in the NRECA Medicare Part D Prescription Drug Plan or another
creditable plan.
Keep in mind: If you are eligible for Medicare and your dependents are not Medicare-eligible
then your dependents will remain covered under the prescription drug benefit of the Plan until
Medicare becomes their primary insurer.
Creditable Coverage For Medicare
Medicare-eligible participants should be enrolled in a creditable prescription drug plan to avoid
paying higher premium charges when enrolling in a Medicare Part D Prescription Drug plan. If
you are covered as an active employee or director and become eligible for Medicare benefits, it is
important to check with your co-op or contact NRECA’s MCC to verify whether the
prescription drug benefit offered by your co-op is considered creditable prescription drug
coverage. Creditable prescription drug coverage is coverage that expects to pay at least as much
as the standard Medicare Part D Prescription Drug plan will pay. Many of the prescription drug
plans offered by NRECA are considered creditable prescription drug coverage. If you remain
enrolled in a prescription drug plan that is not considered creditable coverage after you become
eligible for Medicare, or you have a break in creditable coverage of 63 continuous days or longer
before enrolling in a Medicare Part D plan, you may have to pay a higher premium when you
enroll in a Medicare Part D Prescription Drug plan. You may request a Certificate of Creditable
Drug Coverage from the Plan by contacting MCC at:
Member Contact Center
P.O. Box 6007
Lincoln, NE 68506
Phone: (866) 673-2299
FAX: (402) 483-9300
Keep in mind: If you are an active employee or a dependent covered under this Plan and you
become eligible for Medicare and this Plan does not provide creditable drug coverage, you may
be eligible to switch to coverage under another NRECA Plan (if your co-op offers another
NRECA medical plan option). Please contact NRECA Employee Benefit Services if you believe
you qualify for further information and eligibility requirement at (866)673-2299.
Coordination of Benefits
The Plan does not provide for coordination of benefits for prescription drug charges. This
means that the Plan will pay for any drug charges submitted first to NRECA. If the participant
first submits drug charges to his or her other insurance and subsequently submits them to
NRECA as a secondary payor, NRECA will not consider those drug charges for payment.
Chapter 7:
Prescription Drug Claims and Appeals
Claims and Appeals Procedures
Internal and external claims and appeals processes are available under this Plan.
60
Internal Process for Filing Prescription Drugs Appeals
There are two different appeals processes for prescription drug appeals. The Plan takes the
position that a request to fill a prescription does not constitute a claim. Once you have
completed the initial appeals process – you will have the opportunity to file for an external
review of your claim. Please use the following information to determine which process you will
follow in the table below:
Filing Standard Prescription Drug Appeals and filing for CVS Caremark Clinical/Prior
Authorization Appeals Process
If your prescription is denied at the retail pharmacy or mail service pharmacy (examples include,
but are not limited to, eligibility determinations, co-pay issues, Dispense As Written (DAW) cost
penalty or for specific exclusions under NRECA’s prescription benefit), you have the right to file
an appeal. Please follow the table below for “Standard Prescription Drug Appeals Process”
Also, if your prescription is denied at the retail pharmacy or mail service pharmacy or is initially
denied by CVS Caremark due to a denial of a prior authorization request or submitted claim, you
have the right to file an appeal. Please follow the table below for “Standard Prescription Drug
Appeals Process”. Please see Chapter 6 to determine which drugs require prior-authorization by
CVS Caremark in this appeals process.
CBA Clinical/Prior Authorization Appeal Process for Filing Prescription Drug Appeals
If your prescription is denied at the retail pharmacy or mail service pharmacy or is initially denied
by CBA due to a denial of a prior authorization request or a submitted claim, you have the right
to file an appeal. Please follow the table below for “CBA Clinical/Prior Authorization Appeal
Process”. Pease see Chapter 6 to determine which drugs require prior-authorization by CBA.
The table on the following pages explains the process for filing prescription drug appeals. If you
need more information, please contact CBA at 402-483-9200 or CVS Caremark Customer Care
at 888-796-7322.
INTERNAL PROCESS FOR FILING PRESCRIPTION DRUG APPEALS
Please follow the
following column
for your appeals
process:
Your right to
appeal:
STANDARD
PRESCRIPTION DRUG
APPEALS PROCESS
(CLINICAL DENIAL BY
CVS/CAREMARK FOR
PRIOR AUTHORIZATION)
If your prescription is denied at
the retail pharmacy or mail
service pharmacy or if your
prescription is denied by CVS
Caremark due to an adverse
determination for prior
authorization on a submitted
claim, you have the right to file
an appeal. The list of drugs that
require a Prior Authorization
from CVS Caremark are noted
above. You may also contact
CVS Caremark at 888-796-7322
61
CBA CLINICAL/PRIOR
AUTHORIZATION APPEAL
PROCESS FOR FILING
PRESCRIPTION DRUG APPEALS
(CLINICAL DENIAL BY CBA)
If your prescription is denied at the
retail pharmacy or mail service
pharmacy or is initially denied by
CBA due to an adverse determination
for a prior authorization or a
submitted claim, you have the right to
file an appeal. The list of drugs that
require a Prior Authorization from
CBA are noted above. You may also
contact CBA at 402-483-9200 for
further information on how to file a
clinical appeal.
Please follow the
following column
for your appeals
process:
STANDARD
PRESCRIPTION DRUG
APPEALS PROCESS
(CLINICAL DENIAL BY
CVS/CAREMARK FOR
CBA CLINICAL/PRIOR
PROCESS FOR FILING
for further information on how
to file a clinical appeal.
Not later than 180 days from the date you receive the notices that your
Time period
claim is denied.
that you, or
your authorized
representative,
have to request
a claim appeal:
“Authorized
representative”
definition:
A person you authorize in writing to act on your behalf. An authorized
representative may be your Physician. If the authorized representative is
someone other than your Physician or authorized agent, you must
authorize the person in writing to act on your behalf.
How to
designate an
authorized
representative:
Call CVS Caremark at 888-7967322 to request a form. Fill out
the form “Authorization for a
one-time written release of
personal health information.”
Send the form to:
Caremark
Attn: Research Department
P.O. Box 832407
Richardson, TX 75083
Fill out the form “Authorization to
Use and Disclose Protected Health
Information.” Send the form to:
Privacy Officer
National Rural Electric Cooperative
Association
Copies of all documents, records and other information related to your
Information
denied claim.
you may
request from
the Plan or CVS
Caremark free
of charge:
Materials that
you may
submit with
your appeal:
Written comments, records, documents and other information to support
your appeal, whether or not you already submitted these items.
Submit your
written appeal
to:
The appeals process begins by
contacting CVS Caremark
Customer Care – 888-796-7322.
Once a participant or participant’s
representative contacts CVS
Caremark with a request to appeal,
the participant will be instructed on
62
Appeals Administrator
c/o Cooperative Benefit
P.O. Box 6249
Lincoln, NE 68506
In the case of an Urgent Care
appeal, the participant may make
STANDARD
PRESCRIPTION DRUG
APPEALS PROCESS
(CLINICAL DENIAL BY
CVS/CAREMARK FOR
Please follow the
following column
for your appeals
process:
how to submit an appeal.
CBA CLINICAL/PRIOR
PROCESS FOR FILING
the request by phone.
Appeals can be submitted to CVS
Caremark via fax or by mail to the
following address:
CVS Caremark
Prescription Claim Appeals MC
109
P.O. Box 52084
Phoenix, AZ 85072-2084
Fax # - 866-689-3092
In the case of an Urgent Care
appeal, the participant’s Physician
may make the request by phone.
The Appeals Administrator is a
different person than the person
who made the original decision to
deny your claim and is not
someone directly supervised by the
original decision-maker.
Identity of the
Appeals
Administrator:
Appeal determinations for clinical
benefits are reviewed by a CVS
Caremark Appeals Analyst, who is
a different person than the person
who made the original decision to
deny your claim and is not
someone directly supervised by the
original decision-maker.
Time period
that the
Appeals
Administrator
has to review
your appeal
and make a
decision:
Appeals are to be processed within the following time frames from the
date complete information is received from the participant:
If your appeal
is denied, you
will receive a
notice that
contains:
•
Specific reasons why your
appeal is denied
•
Specific reasons why your
appeal is denied
•
Reference to the specific Plan
provisions on which the denied
appeal is based
•
Reference to the specific Plan
provisions on which the denied
appeal is based
•
An explanation of your rights
under ERISA’s claim and
•
An explanation of your rights
under ERISA’s claim and
Pre-Service – 15 days
Post- Service – 30 days
Urgent Care – 72 hours
63
STANDARD
PRESCRIPTION DRUG
APPEALS PROCESS
(CLINICAL DENIAL BY
CVS/CAREMARK FOR
Please follow the
following column
for your appeals
process:
CBA CLINICAL/PRIOR
PROCESS FOR FILING
appeal rules
•
appeal rules.
This communication will
include information on how to
file a mandatory second-level
appeal with CBA.
You have now completed CVS
Caremark’s appeal process. You
may request an External Review
(see “External Review Process for
Claims Denials and Coverage
Rescissions” in Chapter 5), or you
may seek legal action under ERISA
within 12 months from the date of
this appeal.
If you do request an External
Review, you also have the right to
file a civil action under ERISA
within 12 months after the date you
receive the External Review
decision.
Chapter 8:
•
This communication will
include information on how to
file a Voluntary Final Appeal
with
CBA.
You have now completed the
Plan’s internal appeal process.
You may request an External
Review (see “External Review
Process for Claims Denials and
Coverage Rescissions” in Chapter
5), or you may seek legal action
under ERISA within 12 months
from the date of this appeal.
If you do request an External
Review, you also have the right to
file a civil action under ERISA
within 12 months after the date you
receive the External Review
decision.
Mental Health and Substance Abuse Benefits
Mental Health and Substance Abuse Benefits are designed to help you and your family receive
the appropriate care associated with mental health, substance-related disorders and chemical
dependency problems. The Plan covers charges incurred for the treatment of mental,
psychoneurotic and personality disorders, and substance-related disorders. The Plan pays
benefits for these services under Physician Benefits, Hospital Benefits and Emergency Room
Services (see “Chapter 2”).
To receive the full Hospital benefits for which you are eligible, you must pre-certify any
Hospitalization, including Hospitalization for mental health, substance-related abuse or chemical
dependency treatment. Call SHARE prior to your admission. Otherwise, your benefits will be
reduced (see “Simplified Hospital Admission Review (SHARE)”). For emergency
Hospitalizations, call SHARE within 2 business days of being admitted (see “Simplified Hospital
Admission Review (SHARE)”).
The Partial Hospitalization Program (PHP) provides a short-term, intermediate level of care for
the treatment of mental health and substance-related disorders. PHPs are typically offered within
a psychiatric Hospital or behavioral health department of a Hospital. Patients participate
generally weekdays for 6 to 8 hours at a time as prescribed by their Physician. The Plan considers
64
a partial day to count as one (1) inpatient day, and is subject to the Plan’s inpatient Hospital
benefit limitations.
If you wish to file an appeal under these Benefits, please see Chapter 5.
Life Strategy Program
The NRECA Life Strategy Counseling Program (LSC Program) is available to any Plan
participants who are at least 18 years of age and who wish to seek assistance with
•
problem assessment,
•
education,
•
information, and
•
assistance with initial crisis management.
•
Personal problems may include, but are not limited to:
o family or relationship problems,
o parenting difficulties,
o work related problems,
o substance use and abuse,
o grief and loss,
o emotional and physical abuse,
o thoughts of suicide, or
o anxiety and depression.
Services Under the Life Strategy Counseling Program
The LSC Program will provide you with a dedicated Master-level telephonic counselor from APS
Healthcare, Inc. who will work with you. You will have unlimited access to telephonic counseling
and support 24/7, 365 days/year. These calls will be kept confidential. The Life Strategy
counselor, at your election, can also refer you to a further professional assistance as appropriate.
Access to online resources are also available through cooperative.com.
Keep in mind: Fees incurred at agencies other than through the LSC Program are not included
in this coverage, and you will be responsible for the payment for fees incurred outside of this
Program.
To reach a telephonic counselor at APS Healthcare, Inc. dial (toll-free): 888-225-4289
Exclusions under the Life Strategy Counseling Program
The following services are specifically excluded from the LSC Program:
•
Biofeedback and hypnotherapy;
•
Services required by court order, or as a condition of parole or probation, not, however,
to the exclusion of services to which you would otherwise be entitled;
•
Services for children regarding remedial education including evaluation or medical
treatment of learning disabilities or minimal brain dysfunction; developmental and
learning disorders; behavioral training; or cognitive rehabilitation. The LSC Program
65
shall, however, provide services for parents coping with children who are dealing with
the issues listed out in this bullet point;
•
Medical treatment or diagnostic testing related to learning disabilities, developmental
delays, or educational testing or training;
•
Services provided from a service outside of the LSC Program;
•
Psychological testing;
•
Sleep therapy;
•
Medical treatment of congenital and/or organic disorders associated with permanent
brain dysfunction, including without limitation, organic brain disease, Alzheimer’s disease
and autism. Services that enhance the coping skills of eligible family member is a covered
service;
•
IQ testing;
•
Medical treatment for chronic pain. Services that enhance a participant and eligible
family’s coping skills are covered services;
•
Services involving medication management or medication consultation with a
psychiatrist;
•
Fitness for Duty Evaluations (FFDE);
•
Any form of therapy or counseling considered experimental, investigational or unproven;
or
•
Medical treatment of any kind.
Chapter 9:
Plan Information
Plan Name: The Plan operates under the official name of the National Rural Electric
Cooperative Association’s Group Benefits Program.
Plan Number: 501
Type of Plan: Group health plan
Plan Year: The Plan Year begins on January 1 and ends the following December 31, unless
otherwise designated in the Plan document.
Effective Date: January 1, 2012
Plan’s Self-Insured Status: Coverage under the Plan is self-insured and funded through
contributions made solely by NRECA, or jointly by NRECA and participating cooperatives:
National Rural Electric Cooperative Association
Group Benefits Trust
Administration: Except where pre-empted by ERISA or other U.S. laws, the validity of the Plan
and any other provisions will be determined under the laws of the Commonwealth of Virginia.
66
Plan Sponsor: The name and address of the Plan Sponsor is:
NRECA, as the Plan Sponsor, must abide by the rules of the Plan when making decisions related
to how the Plan operates and how benefits are paid.
Plan Sponsor’s Employer Identification Number: 53-0116145
Plan Administrator and Named Fiduciary: The Plan Administrator has discretionary and
final authority to interpret and implement the terms of the Plan, resolve ambiguities and
inconsistencies, and make all decisions regarding eligibility and/or entitlement to coverage or
benefits. The Plan Administrator is:
Senior Vice-President
Insurance & Financial Services
Telephone number: (703)907-5500
Employer Identification Number: 54-2072724
In addition to the Senior Vice-President of Insurance & Financial Services, the individual listed
below is the person who has Plan Administrator responsibilities for your Employer:
P.O. BOX 520
SIKESTON, MO 63801
Employer Identification Number: 43-0510025
Plan Trustee: The trustee for the Plan is:
State Street Bank and Trust Company
225 Franklin Street
Boston, MA 02101
Claims Administrator: The Claims Administrator for the Plan is:
Cooperative Benefit Administrators, Inc.
P.O. Box 6249
Lincoln, NE 68506
The Claims Administrator for Prescription Drug Benefits under the Plan is:
CVS Caremark, Inc.
P.O. Box 686005
San Antonito, Texas 78268-6005
Agent for Service of Legal Process: The agent of service of legal process is the Plan
Administrator. This is the person who receives all legal notices on behalf of the Plan Sponsor
regarding the claims or suits filed with respect to this Plan. Such legal process may also be
served upon the Plan Trustee.
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Chapter 10:
Administrative Information
Not a Contract of Employment
This Plan must not be construed as a contract of employment and does not give any employee a
right of continued employment. Nor may the Plan be construed as a guarantee of other benefits
from your Employer.
Non-Assignment of Benefits
You cannot assign, pledge, borrow against or otherwise promise any benefit payable under the
Plan before you receive it. The one exception to this provision is in the case of a Qualified
Medical Child Support Order (QMCSO) that requires you to provide benefits to a child.
Third Party Liability
The Plan does not cover expenses that you incur as a result of an injury or sickness caused by a
third party (such as in an automobile accident). This provision of the Plan allows you to receive
benefits, and, at the same time, places the expense of coverage with the person or entity that
caused the injury or sickness. As a condition of receiving benefits under this Plan, you are
expected to cooperate with CBA with its recovery of any amounts for which the Plan is entitled
to be reimbursed, including the completion of any forms, and to repay the Plan any amounts you
receive for loss of income due to the injury or sickness. The Plan will seek recovery for payment
of benefits through subrogation or reimbursement.
Subrogation
Immediately upon paying any benefits to you, the Plan shall be subrogated (that is, substituted
for) all rights or recovery that you have against any party for loss of income due to your injury or
sickness. This means that in the event you receive a settlement, judgment, or compensation
from the third party for your loss of income due to your injury or sickness, the Plan has an
independent right to seek reimbursement of the benefits it paid on your behalf under this Plan.
You must notify the Plan within 45 days of the date when notice is given to any third party of
your intention to recover damages due to your injury or sickness. If you enter into litigation for
payment of your injury or sickness, you must not prejudice, in any way, the subrogation rights of
the Plan. Any costs incurred by the Plan in matters related to subrogation will be paid for by the
Plan. The costs of legal representation you incur will be your responsibility.
Reimbursement
In most cases, the Plan will not be reimbursed directly by the third party. Normally, your claim
against the third party will be settled with the third party. Therefore, if your benefits are paid by
the Plan and then you receive settlement from the third party or the third party’s insurer to
compensate you for your loss of income, you must reimburse the Plan for the benefits it paid to
you up to the amount of such compensation. This Plan’s right of reimbursement is a first
priority right of reimbursement, to be satisfied before payment of any other claims, including
attorney’s fees and costs, and regardless of any state’s make-whole doctrine. If you fail to repay
the Plan any amounts you receive for loss of income due to the injury or sickness, the
Plan reserves the right to bring legal action against you for amounts owed to the Plan
and/or to suspend payment(s) for any future Plan benefits until it has recovered such
amounts.
Mistakes in Payment
Although every effort is made to pay your benefits from the Plan accurately, mistakes can occur.
If a mistake is discovered, the Plan Administrator will make corrections that are deemed
appropriate. You will be notified if a mistake is found.
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Right of Recovery of Overpayment
If it is later determined that the Plan made an overpayment or a payment was made in error to
you or on your behalf, the Plan has a right at any time to recover that overpayment from the
person to whom or on whose behalf the overpayment or erroneous payment was made. The
Plan has the right to recover overpayments as a result of, but not limited to:
•
Fraud;
•
Any error the Plan makes in processing a claim; or
•
Benefits paid after the death of the Employee.
If the overpayment is not refunded to the Plan, the Plan reserves the right to bring a legal action
to recover the overpayment and/or to offset future benefit payments until the overpayment is
recouped. You will be notified if a mistake is found.
Changing or Terminating the Plan
This Plan may be amended or terminated at any time, for any reason, by action of the Plan
Administrator or your Employer. This includes the right to change the cost of coverage. These
changes may be made with or without advance notice to Plan participants. However, your rights
to claim benefits for the period prior to the termination or amendment will not be affected if
such benefit is payable under the Plan as in effect before the Plan is terminated or amended.
Severability
If any provision of this Plan is held invalid, the invalid provision does not affect the remaining
parts of this Plan. The Plan is construed and enforced as if the invalid provision had never been
included.
Chapter 11:
Federal Laws Impacting This Plan
Women’s Health and Cancer Rights Act (WHCRA)
Covered individuals who had or are going to have a mastectomy are entitled to certain benefits
under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). If you receive
mastectomy-related benefits, coverage will be provided in a manner determined in consultation
with the attending Physician and patient for:
•
All stages of reconstruction of the breast on which the mastectomy has been performed;
•
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
•
Prostheses; and
•
Treatment of physical complications at all stages of a mastectomy, including swelling
associated with the removal of lymph nodes (lymphedemas).
These benefits will be provided subject to the same coinsurance applicable to other medical and
surgical benefits provided under this Plan. See “Chapter 2” for specific coinsurance applicable
to these benefits.
If you would like more information on WHCRA, please contact your Benefits Administrator.
Statement of ERISA Rights
Your Rights
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As a participant in the Plan, you are entitled to certain rights and protections under the
Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan
participants shall be entitled to:
Receive Information About Your Plan and Benefits
Examine, without charge, at the Plan Administrator’s office and at other specified locations, such
as worksites, all documents governing the Plan, including insurance contracts, and a copy of the
latest annual report (Form 5500 series), if any, filed by the Plan with the U.S. Department of
Labor and available at the Public Disclosure Room of the Employee Benefits Security
Administration.
Obtain, upon request to the Plan Administrator, copies of documents governing the operation
of the Plan, including insurance contracts and copies of the latest annual report (Form 5500
Series) and updated summary plan description (SPD). The Plan Administrator may make a
reasonable charge for the copies.
Receive a summary of the Plan’s annual Form 5500, if any is required by ERISA to be prepared,
in which case the Plan Administrator, is required by law to furnish each participant with a copy
of this summary annual report.
COBRA and HIPAA Rights
ERISA also provides that all Plan participants will be entitled to:
Continue health care coverage for yourself, your spouse, or your dependents if there is a loss of
coverage under the Plan as a result of a qualifying event. You or your dependents may have to
pay for such coverage. Review this SPD and the documents governing the Plan on the rules
governing your COBRA continuation rights.
Reduction or elimination of exclusionary periods of coverage for preexisting conditions under
your group health plan, if you have creditable coverage from another plan. You should be
provided with a certificate of creditable coverage, free of charge, from your group health plan or
health insurance insurer when you lose coverage under the Plan, when you become entitled to
elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you
request it before losing coverage, or if you request it up to 24 months after losing coverage.
Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion
for 12 months (18 months for late enrollees) after your enrollment date in your coverage.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who
are responsible for the operation of the employee benefit plan. The people who operate your
Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you
and other Plan participants and beneficiaries. No one, including your employer or any other
person, may fire you or otherwise discriminate against you in any way to prevent you from
obtaining a Plan benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to
know why this was done, to obtain copies of documents relating to the decision without charge,
and to appeal any denial, all within certain time schedules. Under ERISA, there are steps that you
can take to enforce the above rights. For instance, if you request a copy of Plan documents or
the latest annual report (Form 5500), if any, from the Plan and do not receive them within 30
days, you may file suit in federal court. In such case, the court may require NRECA, as Plan
Administrator, to provide the materials and pay you up to $110 per day until you receive the
70
materials, unless the materials were not sent because of reasons beyond the control of the Plan
Administrator. If you have a claim for benefits which is denied or ignored in whole or in part,
and if you have exhausted the claims procedures available to you under the Plan, you may file
suit in a state or federal court.
If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated
against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or
you may file suit in a federal court. The court will decide who should pay court costs and legal
fees. If you are successful, the court may order the person you have sued to pay these costs and
fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds
your claim is frivolous.
Assistance with Your Questions
If you have any questions about your Plan, you should contact the Plan Administrator. If you
have any questions about this statement or about your rights under ERISA, or if you need
assistance in obtaining documents form the Plan Administrator, you should contact the nearest
office of the Employee Benefits Security Administration, U.S. Department of Labor (listed in
your telephone directory) or contact the Division of Technical Assistance and Inquiries,
Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution
Avenue, N.W., Washington, D.C. 20210. You may also obtain certain publications about your
rights and responsibilities under ERISA by calling the publications hotline of the Employee
Benefits Security Administration.
HIPAA Privacy Rights
Availability of HIPAA Notice of Privacy Practices
The privacy rules under HIPAA govern how health information about you may be used and
disclosed by the Plan, and provide you with certain rights with respect to your health
information. The Plan maintains a Notice of Privacy Practices that provides information to
individuals whose protected health information (PHI) will be used or maintained by the Plan,
and describe the Plan’s legal duties and privacy practices relative to such information. If you
would like a copy of the Plan’s Notice of Privacy Practices, please contact NRECA’s Privacy
Officer:
Privacy Officer
NRECA
Telephone: (703) 907-6601
Fax: (703) 907-6602
Email: [email protected]
The Plan’s Notice of Privacy Practices is also available on the NRECA Employee Benefit
website at https://benefits.cooperative.com/myaccount in the Document Library>Documents
for Employees>Insurance Plans>All Plans.
Family and Medical Leave Act (FMLA)
The Family and Medical Leave Act (FMLA) requires some employers to maintain group health
insurance for up to 12 consecutive weeks of continuous or intermittent unpaid leave each year
for specific family and medical reasons. FMLA also contains rules regarding the rights of
employees when and if they return from FMLA leave and other issues. Not all employers are
covered by FMLA and not all employees of covered employers are eligible for FMLA rights.
71
Employers subject to FMLA are required to offer up to 26 weeks of FMLA leave to any eligible
employee who is the spouse, daughter, son, parent, or next of kin of a member of the Armed
Forces, to provide care for the service member with a serious injury or illness incurred while on
active duty.
If you and your employer are covered by FMLA and you do not return from work at the end of
a FMLA leave, you may be entitled to elect COBRA, even if you withdrew from coverage under
this Plan during the leave.
Your Benefits Administrator can provide you with specific information on how FMLA affects
you and your benefits.
USERRA (Benefits While on Military Leave)
Under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA),
if you go on active duty in the U.S. Armed Forces or the National Guard of a state that is called
to federal service, you will have certain employment and employee benefit rights upon
completion of duty, provided you were on an authorized military leave of absence.
If your military leave is for 31 days or less, the Plan coverage in effect for you and your
dependents will be continued automatically and your employer will pay the same portion of the
cost as if you were still working. If your military leave is for a period greater than 31 days,
coverage for you and your dependents will be continued under USERRA/COBRA for up to 24
months or until you return from active duty (whichever occurs first), but only if you pay the full
cost of the coverage. All other benefits for you and your dependents terminate as of either the
last day of active employment or compensated leave, but in no case later than the date of your
entry into the armed services.
When you return from military leave, you will be eligible to participate in all applicable benefit
programs upon re-employment without having to again fulfill any waiting periods. You must
enroll within 31 days of re-employment. See your Benefits Administrator for more information.
COBRA Continuation Coverage
Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), when you
experience a qualifying event (described below) that causes you to lose eligibility for medical
coverage under the Plan, you may have the option of continuing that coverage at your own
expense (known as COBRA coverage). COBRA coverage is also available to your qualified
beneficiaries (described below) who lose coverage due to a qualifying event (described below).
Please note, however, that COBRA coverage is available only for the type of Plan coverage you
had at the time of the qualifying event. Nothing in this SPD – except as expressly stated - is
intended to expand your and your dependents’ COBRA rights beyond the minimum COBRA
requirements.
After a qualifying event occurs and you have provided proper notice to your employer, if
required, your employer must offer COBRA coverage to each qualified beneficiary. You, your
spouse, and/or your dependent children would be qualified beneficiaries and thus entitled to
elect COBRA if you, your spouse, and/or your dependent children lose coverage under the Plan
because of the qualifying event. (Certain newborns, newly adopted children, and alternate
recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail
below.)
Qualified Beneficiaries – Qualified Beneficiaries are individuals who are Plan participants on
the day before a qualifying event occurs. Generally, this applies to you, your spouse and your
dependent children. It also includes a child born to, placed for adoption, or legal guardianship
with you during the period of COBRA coverage, and alternate recipients under QMCSOs.
Individuals who have terminated coverage under this Plan because they have other coverage are
72
not considered qualified beneficiaries for COBRA. If your Plan covers Domestic Partners,
Domestic Partners are eligible for COBRA coverage.
Qualifying Event—A qualifying event is a specific event that causes you or your covered
dependents to lose coverage under this Plan.
Qualifying events for the covered employee include:
• Termination (voluntary or involuntary, including retirement) of employment for any
reason other than gross misconduct; or
• Reduction in work hours that results in loss of medical coverage.
Qualifying events for your covered spouse include:
•
•
•
•
Your divorce;
The employee’s death (see below “Special Rules for Death as the Qualifying Event”);
The employee’s reduction in work hours are reduced, resulting in a loss of coverage; or
The employee’s termination of employment for any reason other than gross misconduct.
Qualifying events for your dependent children include:
• The employee-parent’s death (see below “Special Rules for Death as the Qualifying
Event”);
• The employee-parent’s reduction in work hours are reduced, resulting in a loss of
coverage; or
• The employee-parent’s termination of employment for any reason other than gross
misconduct; or
• The dependent child ages out of coverage.
Qualifying events for retirees and their dependents also include:
• Your employer files for bankruptcy; or
• Your entitlement to Medicare followed by a loss of coverage (qualifying event for spouse
and dependent children only).
Please note the following: Your right to post-retirement benefits is subject to the policies of your
employer and can change at any time.
In considering whether to elect COBRA, you should take into account that a failure to elect
COBRA will affect your future rights under federal law. First, you can lose the right to avoid
having preexisting condition exclusions applied to you by other group health plans if you have
more than a 63-day gap in health coverage, and election of COBRA may help you not have such
a gap. Second, you may lose the guaranteed right to purchase individual health insurance policies
that do not impose such preexisting condition exclusions if you do not get COBRA coverage for
the maximum time available to you. Finally, you should take into account that you have special
enrollment rights under federal law. You have the right to request special enrollment in another
group health plan for which you are otherwise eligible (such as a plan sponsored by your
spouse's employer) within 30 days after your group health coverage under the Plan ends because
of one of the qualifying events listed above. You will also have the same special enrollment right
at the end of COBRA coverage if you elect COBRA coverage for the maximum time available to
you.
When your medical coverage or COBRA coverage ends, you will receive a certificate of
creditable coverage. (Certification will also be provided for a dependent’s loss of coverage once
the Plan is aware that the dependent’s coverage has ended. Please keep your employer informed
if your dependents become ineligible for coverage.)
73
Procedures for Notifying Your Employer of Qualifying Events
Failure to follow the procedures for notifying your employer, listed in the paragraphs below, will
result in the loss of eligibility for COBRA coverage.
Which Qualifying Events Require Employer Notification
You or your spouse must notify your employer of the following qualifying events:
• Your divorce;
• Loss of dependent eligibility for your dependent child;
• Your death;
• Determination by the Social Security Administration (“SSA”) that you, your spouse or
your dependent child is disabled;
• Determination by the SSA that you, your spouse or your dependent child is no longer
disabled; or
• Second qualifying event (that is, a qualifying event that you, your spouse or your
dependent child experiences during the 18-month COBRA coverage period that follows
an employment-related qualifying event).
Who Must Receive the Notification at your Employer
You must notify the person who is named in the General Notice of COBRA Continuation Rights as
the Plan Information Contact.
When Your Employer Must be Notified
You or your spouse must provide notice to your employer within 60 days after the date of the
qualifying event or the second qualifying event.
In the event of a SSA disability determination and you (your spouse and/or your dependent
children) want to elect to extend the initial 18-month continuation period for an additional 11
months, your employer must be notified within 60 days after the later of the SSA disability
determination (but before the end of the initial 18-month period) or the date of the qualifying
event.
In the event that the SSA has determined that you, your spouse or your dependent child is no
longer disabled, your employer must be notified within 30 days after the SSA determination.
How Your Employer Must be Notified
The required information for notification of your employer must be provided on the form and in
the format specifically required by your employer for this purpose. This form, required by your
employer, will be available at no cost upon request from the Plan Information Contact named in
the General Notice of COBRA Continuation Rights.
What Information and/or Documentation the Notification Must Include
•
•
•
•
•
Name of the qualified beneficiary(ies)
Address of the qualified beneficiary(ies)
Telephone number(s) of the qualified beneficiary(ies)
Qualifying event
Date of the qualifying event
Your employer may require additional information or documentation as proof of the qualifying
event. Examples of such additional information or documentation include:
•
If the qualifying event is divorce, copies of the first and last page of the divorce decree.
74
•
•
•
If the qualifying event is loss of dependent eligibility, a statement as to the reason (for
example, age limit reached).
If notifying the employer of a SSA disability determination, a copy of the SSA
determination letter.
If the qualifying event is the death of the employee, a copy of the death certificate.
Your employer reserves the right to request additional information or documentation if the
information or documentation you provided is not sufficient for your employer to make its
determination.
Who May Provide the Notification
•
•
•
•
You as a covered employee may provide notice on behalf of yourself, your spouse
and/or your dependent children.
Your spouse may provide notice on behalf of him/herself and/or your dependent
children.
Your dependent child may provide notice on his/her own behalf.
Any representative acting on behalf of you, your spouse, and/or your dependent children
may provide notice.
Notice provided to your employer by one qualified beneficiary is considered notice on behalf of
all related qualified beneficiaries.
How You Will Be Notified by Your Employer If COBRA Coverage Is Available
If COBRA coverage is available as a result of an initial qualifying event, your employer will
provide you (your spouse and/or your dependent children) with an election notice and an
election form. The election notice contains information regarding COBRA rights to continued
coverage. The election form is an administrative form to continue NRECA-sponsored health
coverage.
If the COBRA coverage period will be extended due to a second qualifying event (including a
SSA disability determination), you will be notified by your employer of the extended coverage
period.
If COBRA does not apply, your employer will send you (your spouse and/or your dependent
children) a Notice of Unavailability of Coverage, explaining the reasons why COBRA coverage is
not available.
Electing COBRA Coverage
Once the benefits administrator receives notice that a qualifying event has occurred, you will
receive a notice describing your right to elect COBRA coverage. Each qualified beneficiary will
have an independent right to elect COBRA coverage. You may elect COBRA coverage on behalf
of your spouse, and you or your spouse may elect COBRA coverage on behalf of your children.
If you (your spouse and/or your dependent children) wish to continue coverage under
this Plan, you (or they) must respond to the notice within 60 days of the date you (or
they) receive the notice or the date of the qualifying event, whichever is later. If mailed,
your election must be postmarked (or if hand-delivered, your election must be received
by your employer) no later than this date. Failure to respond to the notice within this 60day period will result in the loss of the right to elect to continue medical coverage. If you
and/or your eligible dependents reject COBRA continuation coverage before the 60-day
due date, you may change your mind as long as you furnish a completed election form
before the 60-day due date. However, if you change your mind after first rejecting
COBRA continuation coverage, your COBRA continuation coverage will begin on the
75
date you furnish the completed election form. Please note that your COBRA coverage
will end at a maximum of 18 months or 36 months, whichever is applicable, from the
date of the qualifying event, unless coverage ends based on an event listed under the
section “When COBRA Coverage Ends” stated below.
You must give this notice to:
P.O. BOX 520
SIKESTON, MO 63801
Length of COBRA Coverage
If you and/or your eligible dependents elect COBRA coverage, the coverage begins on the date
of the qualifying event. If you and/or your eligible dependents reject COBRA continuation
coverage before the 60-day due date, you may change your mind as long as you furnish a
completed election form before the 60-day due date. However, if you change your mind after
first rejecting COBRA continuation coverage, your COBRA continuation coverage will begin on
the date you furnish the completed election form. Please note that your COBRA coverage will
end at a maximum of 18 months or 36 months, whichever is applicable, from the date of the
qualifying event. COBRA coverage can end before the end of the maximum coverage period for
several reasons, which are described in the section below entitled “When COBRA Coverage
Ends”.
COBRA coverage is temporary. Depending upon the qualifying event, the duration of COBRA
coverage is as follows:
• 18-Month COBRA Coverage Period
If the qualifying event is your termination of employment (except for gross misconduct)
or reduction in hours, you, your spouse and/or your dependent children are entitled to
elect COBRA coverage for a maximum period of 18 months after the qualifying event.
• 36-Month COBRA Coverage Period
If the qualifying event is divorce, your death (see “Special Rules for Death as a
Qualifying Event” below), your entitlement to benefits from Medicare (retirees only) or
the loss of dependent eligibility, your spouse and/or your dependent children are
entitled to elect COBRA coverage for a maximum period of 36 months after the
qualifying event.
If the qualifying event resulting in a loss of Plan coverage was termination of
employment (including retirement), or reduction in work hours, and you become entitled
to Medicare benefits less than 18 months before the qualifying event date, COBRA
coverage under the Medical Plan for qualified beneficiaries (other than the employee)
who lose coverage as a result of the qualifying event can last until up to 36 months
(depending on when Medicare entitlement occurs) after the date of Medicare
entitlement.
For example, if a covered employee becomes entitled to Medicare eight months before
the date on which his employment terminates, COBRA coverage for his spouse and
children who lost coverage as a result of his termination can last up to 36 months after
the date of Medicare entitlement, which is equal to 28 months after the date of the
qualifying event (36 months minus eight months). This COBRA coverage period
76
extension is available only if the covered employee becomes entitled to Medicare within
18 months BEFORE the termination or reduction of hours.
• Disability Extension to 18-Month COBRA Coverage Period
If the qualifying event is your termination of employment (except for gross misconduct)
or reduction in hours, and you, your spouse or your dependent child (i) has elected
COBRA coverage, (ii) is determined by the Social Security Administration to be disabled
and (iii) notifies the benefits administrator in a timely fashion, then you, your spouse and
your dependent children may be entitled to receive up to an additional 11 months of
COBRA coverage, for a total of 29 months. The disability must have started at some
time before the 60th day of COBRA continuation coverage and must last at least until
the end of the initial 18-month period of COBRA coverage.
• Second Qualifying Event to 18-Month COBRA Coverage Period
If you or your eligible dependents experience another qualifying event during the 18month COBRA coverage period that would otherwise entitle your spouse and/or
dependent children to 36 months of COBRA coverage, the 18-month period will be
extended to a maximum of 36 months for your spouse and/or dependent children, if
notice of the second qualifying event is properly given to the Plan. The second
qualifying event may be your death (see below “Special Rules for Death as a Qualifying
Event”), your divorce, or your dependent child’s loss of dependent status under the
Plan, 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. To qualify for this
extension you, your spouse or your eligible dependents must notify your employer
within 60 days of the second qualifying event.
Special Rules for Death as the Qualifying Event
If the qualifying event is your death, the maximum COBRA coverage period for the surviving
spouse and dependent children is 36 months. However, for the surviving spouse who has not remarried, coverage may continue beyond the 36-month period until the earlier of the surviving
spouse’s remarriage or the surviving spouse’s death. Coverage for the dependent children may
continue beyond the 36-month period until the earlier of the surviving spouse’s remarriage or
until the date there is a loss of dependent eligibility under the terms of the Plan (see “Coverage
for Your Dependents”).
Cost of COBRA Coverage
If you elect COBRA coverage under the Plan, you must pay the full cost of that coverage
(including both the share you now pay, if any, and the share your employer now pays). You may
also be required to pay a 2% administrative fee, for a total of 102% of the cost. If you are
disabled, this administrative fee may be higher than the 2% but no more than 50% of the cost of
coverage. After you elect COBRA coverage, you will receive a bill for the initial premium. This
initial premium must be paid in full within 45 days of the date you elect COBRA coverage. You
will receive a bill for subsequent premiums before the first day of each month. Each subsequent
premium must be paid in full within 31 days of the first day of each month (for example, the
premium for May must be paid in full on or before May 31). Failure to pay the initial or
subsequent premiums on time will result in the termination of your COBRA coverage.
When COBRA Coverage Ends
Qualified beneficiaries will lose COBRA coverage if any of the following occurs:
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•
•
•
•
•
•
•
•
Any required premiums are not paid in full within the required payment periods. You
have 45 days from the date you elect COBRA coverage to pay your initial premium, and
31 days from the first of each month to pay each subsequent premium.
Your former employer terminates group medical coverage for all employees.
A qualified beneficiary becomes covered, after electing COBRA, under another group
health plan (but only after any exclusions of that other plan for preexisting conditions of
the qualified beneficiary have been exhausted or satisfied).
A qualified beneficiary becomes entitled to Medicare (under Part A, Part B, or both) after
electing COBRA. All other family members that may be qualified beneficiaries remain
eligible to participate in COBRA.
You must notify your employer in writing within 30 days if, after electing COBRA, a
qualified beneficiary becomes entitled to Medicare (Part A, Part B, or both) or becomes
covered under other group health plan coverage. You must use the Plan's form entitled
“Notice of Other Coverage, Medicare Entitlement, or Cessation of Disability Form”.
o You may obtain a copy of this form from your employer at no charge, and you
must follow the notice procedures specified below in the section entitled “Notice
Procedures.” In addition, if you were already entitled to Medicare before electing
COBRA, notify your employer of the date of your Medicare entitlement.
During a disability extension period, the disabled qualified beneficiary is determined by
the Social Security Administration to be no longer disabled (COBRA coverage for all
qualified beneficiaries, not just the disable qualified beneficiary, will terminate).
o If a disabled qualified beneficiary is determined by the Social Security
Administration to no longer be disabled, you must notify your employer of that
fact within 30 days after the Social Security Administration's determination. You
must use the Plan's form entitled “Notice of Other Coverage, Medicare
Entitlement, or Cessation of Disability Form” (you may obtain a copy of this
form from your employer at no charge.
A qualified beneficiary reaches the end of the maximum 18-month, 29-month, or 36month COBRA coverage period (in general), whichever applies.
COBRA coverage may also be terminated if for any reason the Plan would terminate
coverage of a participant or beneficiary not receiving COBRA coverage (such as fraud).
Please remember that in order to protect your family’s rights, you should keep the Benefits
Administrator informed of any changes in the addresses of your family members. You should
also keep for your records copies of any notices you send to the Benefits Administrator.
If you have questions concerning your Plan or your COBRA coverage rights, please contact:
P.O. BOX 520
SIKESTON, MO 63801
More Information About Individuals Who May Be Qualified Beneficiaries
A child born to, adopted by, or placed for adoption with a covered employee during a period of
COBRA coverage is considered to be a qualified beneficiary provided that, if the covered
employee is a qualified beneficiary, the covered employee has elected COBRA coverage for
himself or herself. The child's COBRA coverage begins when the child is enrolled in the Plan,
whether through special enrollment or open enrollment, and it lasts for as long as COBRA
coverage lasts for other family members of the employee. To be enrolled in the Plan, the child
must satisfy the otherwise applicable Plan eligibility requirements (for example, regarding age).
78
A child of the covered employee who is receiving benefits under the Plan pursuant to a QMCSO
received by the Plan during the covered employee's period of employment with the employer is
entitled to the same rights to elect COBRA as an eligible dependent child of the covered
employee.
Chapter 12:
Definitions
Accident - A non-occupational injury that is caused by a sudden and unforeseen event and is
exact as to the time and place it occurred.
Ambulatory Surgical Center - Any public or private institution that:
•
Is licensed as an Ambulatory Surgical Center by the state in which the center is located,
or
•
Is established, equipped, and operated primarily as a facility for performance of surgical
procedures and meets the following requirements:
o Is operated under the supervision of a staff of Physicians, maintains adequate
medical records for each patient, and provides for periodic review of the facility
and its operation by a utilization and/or tissue committee composed of
Physicians other than those owning or supervising the facility;
o Permits a surgical procedure to be performed only by a Physician privileged to
perform such procedure in a Hospital in its area and requires that a licensed
anesthesiologist administer the anesthetics and be present during the surgical
procedure, unless only local infiltration anesthetics are used;
o Provides no overnight accommodations for patients and has at least two
operating rooms and one post-anesthesia recovery room and full-time services of
registered nurses for patient care in all operating and post-anesthesia recovery
rooms;
o Is equipped to perform diagnostic x-ray and laboratory examinations required in
connection with the surgery to be performed and has the necessary equipment
and trained personnel to handle foreseeable emergencies including, but not
limited to, a defibrillator for cardiac arrest, a tracheotomy set for airway
obstruction, and a blood bank or other supply for hemorrhaging; and
o Maintains written agreements with one or more Hospitals in its area for
immediate acceptance of patients who develop complications or require
postoperative confinement.
The surgical suite or facility must be accredited by either the Accreditation for Ambulatory
Health Care (AAHC) or the American Association of Accreditation Plastic Surgery Facilities
(AAAPSF).
Birthing Center - A facility that can be used instead of a Hospital setting for the birth of a child.
A Birthing Center must meet several requirements. It must:
•
Be certified or approved by a state department of health or other legally constituted
regulatory state authority;
•
Be equipped and operated primarily for the purpose of providing an alternative method
of childbirth (This does not include an abortion center or clinic.);
•
Operate under the direction of a Physician;
79
•
Permit a surgical procedure to be performed only by a Physician;
•
Require an examination by an obstetrician at least once prior to delivery (to screen out
high-risk pregnancies);
•
Offer prenatal and postpartum care;
•
Provide at least two birthing rooms;
•
Have available the necessary equipment and trained personnel to handle foreseeable
emergencies. This equipment shall include a fetal monitor, incubator and resuscitator;
•
Provide the services of registered graduate nurses for patient care;
•
Not provide beds or other accommodations for patients to stay more than 48 hours;
•
Maintain written agreements with one or more Hospitals in the area for immediate
acceptance of patients who develop complications or who require post-delivery
confinement;
•
Provide for periodic review by an outside agency; and
•
Maintain adequate medical records for each patient.
Chemotherapy—Outpatient treatment of disease using chemical agents.
Convalescent Nursing Home—A legally operated institution that:
•
For a fee, provides room, board and 24-hour care by one or more professional nurses
and other nursing personnel needed to provide adequate medical care;
•
Is under full-time supervision of a Physician or registered nurse;
•
Keeps adequate medical records;
•
If not operated by a Physician, has the services of one available under an established
agreement;
•
Is not an institution, or part of one, used mainly as a rest facility or a facility for the aged;
and
•
Is licensed for skilled nursing care.
Cosmetic Procedures—A treatment or surgery that is for the purpose of improving the
patient's physical appearance, from which no significant improvement in physiologic function
can be expected, regardless of emotional or psychological factors, and that is not Medically
Necessary.
Custodial Care— Care that helps you with your daily living activities. Examples include
assistance in walking and getting in and out of bed, aid in bathing, dressing, eating and other
forms of assistance with normal bodily functions, and preparation of special diets and
supervision of medication which usually can be self-administered. This type of care does not
require the continuing attention and assistance of licensed medical or trained paramedical
personnel. Custodial Care is not covered under this Plan.
Durable Medical Equipment—Equipment includes, but is not limited to: wheelchairs,
Hospital beds, and respirators. Air conditioners, humidifiers, air purifiers, and other similar
convenience items are not considered Durable Medical Equipment.
80
Durable Medical Equipment is equipment that is recognized as such by Medicare Part B that
meets all of the following criteria:
•
It can stand repeated use,
•
It is primarily and customarily used to serve a medical purpose rather than being
primarily for comfort or convenience,
•
It is usually not useful to a person in the absence of sickness or injury,
•
It is appropriate for home use,
•
It is related to the patient's physical disorder,
•
It is for temporary use only,
•
It is certified, in writing by a Physician, as being Medically Necessary,
•
It is the standard, basic model rather than a deluxe, luxury model,
•
It is not more costly than alternative services that would be effective for diagnosis and
treatment of the condition, and
•
It enables a patient to make reasonable progress in treatment.
Emergency Medical Condition – A medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a prudent layperson, who possesses an
average knowledge of health and medicine, could reasonably expect the absence of immediate
medical attention to result in:
•
Placing the health of the individual in serious jeopardy;
•
Serious impairment to bodily functions; or
•
Serious dysfunction of any bodily organ or part.
ERISA—The Employee Retirement Income Security Act of 1974, as amended.
Home Health Care Agency—A Home Health Care Agency is considered to be one of the
following:
•
A Hospital that provides a program of home health care;
•
A home health agency as defined by Medicare; or
•
An organization that is certified by the patient's Physician as an appropriate provider of
home health services, is licensed or certified as a Home Health Care Agency if the state
or local jurisdiction in which it is located requires such licensing or certification, has a
full-time administrator, keeps written records of services provided to the patient, and has
at least one registered nurse (R.N.) or the nursing care of an R.N. available.
Benefits for services provided by Home Health Care Agencies are subject to the following
conditions:
•
The patient must be under the care of a Physician who submits a home health care plan.
This is a written program for care and treatment of a sickness or injury in the patient's
home. It must certify that inpatient confinement in a Hospital, Convalescent Nursing
Home or skilled nursing facility would be required if the home care weren't provided;
and
81
•
The services and supplies must be ordered by a Physician as a part of the home health
care plan. They must be furnished during the period of inpatient confinement in a
Hospital, convalescent nursing home or skilled nursing facility would be required were it
not for the home health care.
Hospice Care Program— A program directed by a Physician to help care for a Terminally Ill
person through either:
•
A centrally-administered, medically directed and nurse-coordinated program that
provides a coherent system primarily of home care, uses a hospice team, and is available
24 hours a day, seven days a week, or
•
Confinement in a hospice. A hospice is a facility that provides short periods of stay for a
Terminally Ill person in a home-like setting for either direct care or respite. This facility
may be either freestanding or affiliated with a Hospital. It must operate as an integral part
of the Hospice Care Program. If such a facility is required by a state to be licensed,
certified, or registered, it must also meet that requirement to be considered a hospice.
A Hospice Care Program must meet standards set by the National Hospice Organization and be
approved by the Plan. If such a program is required by a state to be licensed, certified, or
registered, it must also meet that requirement to be considered a Hospice Care Program.
Hospital— An institution:
•
that is accredited as a Hospital under the Hospital Accreditation Program of the Joint
Commission on the accreditation of Hospitals, or
•
that is operated in accordance with the law, under the supervision of a staff of Physicians
and with 24-hour-a-day nursing service, and which is primarily engaged in providing:
o general inpatient medical care and treatment of sick and injured persons through
medical, diagnostic and major surgical facilities, all of which facilities must be
provided on its premises or under its control; or
o specialized inpatient medical care and treatment of sick or injured persons
through medical and diagnostic facilities (including x-ray and laboratory) on its
premises, under its control, or through a written agreement with a Hospital or
with a specialized provider of those facilities.
An institution that does not meet the tests of the above items, but which is state licensed and
accredited by the Joint Commission for Accreditation of Hospitals as a community mental health
center and residential treatment facility for alcoholism and drug abuse or as an Ambulatory
Surgical Center.
In no case will the term "Hospital" include a Convalescent Nursing Home or include an
institution that:
•
Is used principally as a convalescent facility, rest facility, nursing facility or facility for the
aged, or
•
Furnishes primarily domiciliary or Custodial Care, including training in the routines of
daily living, or
•
Is operated primarily as a school.
Except that for care of alcoholism, mental illness and substance abuse, the term "Hospital" also
means an alcohol dependency treatment center, psychiatric day treatment facility, and drug
dependency treatment center respectively.
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Hospital Confinement—A covered person is considered confined when he or she is a
registered patient in a Hospital and a room and board charge is made. A Hospital Confinement
for more than 24 hours is considered an inpatient expense regardless of whether a room and
board charge is incurred, e.g., charges for observation exceeding 24 hours.
Immunization—An injection with a specific antigen to promote antibody formation. It is used
to make you immune to a disease or less susceptible to a contagious disease.
Medical Emergency—A sudden and unexpected physical condition for which services are
required to provide an immediate diagnosis and treatment to avoid threat to life or limb if
medical services are not rendered immediately.
Any medical treatments or services that you receive must be “Medically Necessary” as
determined under the Plan.
Medically Necessary or Medically Necessary Services and Supplies—To be considered
"Medically Necessary," medical services or supplies must be:
•
Ordered by a Physician;
•
Consistent with the symptom or diagnosis and treatment of the sickness or injury;
•
Appropriate within the standards of good medical practice;
•
The most appropriate supply or level of service that can be safely provided to the patient
in the appropriate setting;
•
Not solely for the convenience of you, a Physician, Hospital or other medical care
facility;
•
Not for educational, investigational, or experimental services;
•
Not for services that are mainly for the purpose of medical or other research; and
•
Not for Cosmetic Procedures provided solely to improve appearance unless due to a
congenital defect that impairs function, or an Accident.
For Hospital inpatient care to be considered as “Medically Necessary,” the patient’s symptoms
or medical conditions must be such that the services cannot be safely provided on an outpatient
basis.
In the case of a Hospital Confinement, the length of the confinement and Hospital services and
supplies will be considered "Medically Necessary" only to the extent that they are determined to
be both:
•
Related to the treatment of the sickness or injury, and
•
Not provided for the scholastic education or vocational training of the patient.
Charges incurred for examinations to determine the need for hearing aids or the need to adjust
hearing aids are considered unnecessary services.
Physician— A Physician or doctor is defined to include a legally qualified medical doctor or
practitioner who is licensed in the governing jurisdiction and practicing within the scope of the
license. The Physician or doctor must not be related to the participant by blood or marriage.
Radiation Therapy—Outpatient treatment of disease through high energy x-rays or radioactive
substances.
83
Reasonable and Customary (R&C) Rates— The R&C Rates are the current, most common
charge in a geographic area for a particular treatment or service, as determined by CBA. These
charges are researched by CBA and are reviewed on a regular basis.
The R&C Rate for any service or supply is the usual charge of the provider for the service or
supply in the absence of the insurance, but not more than the prevailing charge in the area for a
like service or supply.
A “like service” is of the same nature and duration, requires the same skill, and is performed by a
provider of similar training and experience.
A “like supply” is one that is identical or substantially equivalent.
"Area" means the municipality (or, in the case of a large city, the subdivision of it) in which the
service or supply is actually provided or such greater area as is necessary to obtain a
representative cross-section of charges for a like service or supply.
In setting R&C Rates, CBA takes into account factors such as:
•
The nature and duration of the service;
•
The skill required to perform that service;
•
The training and experience of the provider who performs the service; and
•
The medical supplies necessary for the treatment or service.
Speech Therapy—Therapy by a qualified Speech Therapist is to restore speech loss, or correct
an impairment, due to:
•
A congenital defect for which corrective surgery has been performed, or
•
An injury or sickness
Speech Therapist—Someone who meets all these conditions:
•
Has a master's degree in speech pathology;
•
Has completed an internship;
•
Is licensed by the state in which he or she performs his or her services, if that state
requires licensing; and
•
Is not someone related to you or your dependent by blood or marriage.
Terminal Illness—A condition that limits a person’s life expectancy to six months or less.
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2012 NRECA Medical Plan (High Deductible PPO

Transcription

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