NACOG
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Status Change |
Sample of Changes Permitted |
Sample of Changes Not Permitted |
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Legal Marital Status*, including: |
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Marriage
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Enroll employee (and family) Add child(ren) or spouse Drop coverage, but elect under spouse’s plan |
Drop coverage, but not elect under spouse’s plan
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Divorce, legal separation, Annulment or death of spouse
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Drop spouse coverage Elect employee/dependent coverage if covered under deceased spouse’s plan |
Drop child(ren) coverage
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Number of Dependents*, including: |
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Birth, Adoption or Placement for adoption |
Enroll employee (and family) Add child(ren) or spouse
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Drop coverage for employee, spouse or child(ren)
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Death of a Dependent |
Drop coverage for deceased dependent
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Add coverage |
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Change in Employment Status (by employee, spouse, or dependent resulting in gain or loss of coverage) |
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Commence Employment (Example: spouse begins employment)
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Elect coverage under spouse’s plan and drop under employee’s plan |
Drop coverage, but not elect coverage under spouse’s plan |
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Employment hours reduced for employee (assumes loss of benefits eligibility): Switch from full-time to part-time, strike or lock-out, or starting an unpaid leave |
Elect coverage under spouse’s plan |
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Terminate employment (Example: spouse terminates employment) |
Elect coverage under employee’s plan
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Employment hours increased for employee (assumes new benefits eligibility): Switch from part-time to full-time, return from strike or lock-out, or return from unpaid leave |
Elect coverage under employee’s plan
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Change in Status of Unmarried Dependents (event causes dependent to satisfy or cease to satisfy requirements for coverage)* |
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Marriage Attainment of limiting age Change in student status Change in dependency |
Drop dependent no longer eligible Add newly-eligible dependents
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Drop employee coverage |
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Change in Residence or Worksite (by employee, spouse or dependent resulting in gain or loss of coverage) |
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Change in residence or worksite* |
Change to newly eligible plan
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Change coverage level (e.g., employee to family) |
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Court Judgment/Decree/Order* (see “QMSCO” below”) |
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Add/drop dependent in accordance with decree |
Change coverage, except as permitted by decree |
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Entitlement to (or loss of) Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP), or Loss of Governmental or Educational Institution Coverage** |
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Cancel (or add) coverage of individual eligible (or who lost eligibility) for Medicare or Medicaid Add coverage of individual who lost eligibility for governmental or educational coverage |
Change coverage for individuals who do not gain or lose Medicare or Medicaid coverage Change coverage for individuals who did not lose governmental or educational coverage Change coverage due to gain of governmental or educational coverage |
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Enrollment During Special Enrollment (see “Special Enrollment” below)* |
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Enroll employee (and family) |
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Significant Cost Increase/Curtailment of Benefits |
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Increase premium amount or elect alternative, similar coverage Drop coverage, if no alternative, similar coverage or if curtailment is a loss of coverage |
Drop coverage, if alternative, similar coverage is available Drop coverage if not a loss of coverage |
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Significant Cost Decrease/New or Improved Benefits |
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Decrease premium amount Change to a newly improved or available coverage |
Drop coverage |
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Changes Consistent with Spouse or Dependent Election |
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Annual enrollment of spouse/dependent plan differs, or spouse/dependent makes change in election under their plan due to status change |
Make change consistent with spouse or dependent annual enrollment election or change in election |
Make change not consistent with spouse or dependent annual enrollment election or change in election
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*To make a change, you must notify us of these events within 31 days.
**To make a change, you must notify us of these events within 60 days.
The change in enrollment must be made within 31 days of the event, except in the case of changes related to eligibility under Medicaid, Medicare and CHIP, which must be made within 60 days of the event, and will be effective as of the first day of the month following the date the change is made, except with respect to the addition of coverage for a new child under the age of 18, which will be effective as of the date specified above.
An Employee who fails to enroll for coverage during special enrollment can enroll himself or herself (and his or her Eligible Dependents) only during an open enrollment period or another applicable special enrollment period.
Qualified Medical Child Support Order A QMCSO is a court order requiring coverage of your dependent child. If we receive a QMCSO, we will notify you and revise your coverage accordingly, including deducting the premiums required for such coverage from your paycheck. Once a QMCSO is in effect, no changes to the child’s coverage will be allowed, other than as specified in a QMCSO or upon our receipt of proof that the QMCSO is no longer in effect. You can request a free copy of the Plan’s QMSCO procedures from the Benefits Department.
In accordance with the provisions of the Uniform Employment and Reemployment Rights Act (USERRA), Covered Employees who take a leave of absence to serve in the military may elect to continue coverage under this Plan in accordance with the requirements of USERRA. If such coverage is elected, it will continue until the earlier of 24 months from the date leave began or the day after the date on which the Employee fails to return to work as scheduled and such coverage will count towards any applicable COBRA Coverage period. If the leave is less than 31 days, the Covered Employee shall only be responsible for paying his or her portion of the premium that would have been due had the Covered Employee not been on leave. If the leave exceeds 31 days, the Covered Employee is responsible for paying up to 102% of the entire portion of the premium (i.e., both the Employer’s and Employee’s portions of the premium).
If a Covered Employee takes an approved, unpaid leave that is not an FMLA or USERRA leave, coverage under this Plan will end on the first day of the month following the date on which the leave begins, subject to COBRA Coverage rights. If the Employee returns to work from an approved, unpaid leave as scheduled and in an eligible status (i.e., full-time), the 90-day waiting period described under “When You First Become Eligible” will be waived, and the Employee will be eligible to participate in the Plan as of the first day of the month following the date on which the Employee returns to work.
When Coverage EndsYour (and your Eligible Dependents’) coverage will end on the last day of the month during which your employment ends or you switch to a part-time position, whichever happens first. Your (and your Eligible Dependents’) coverage for any particular benefit will end if you fail to make any required payment for that benefit. If any of your family members cease to be an Eligible Dependent (whether by reason of divorce, separation, age or otherwise), coverage for that individual only will end on the last day of the month during which the family member ceases to be an Eligible Dependent.
When you (or your Eligible Dependents’) coverage ends, “continuation coverage” may be available under a federal law commonly referred to as COBRA (see “Continuation Coverage” below). For further information, refer to the COBRA notice, which will be mailed to your home address when you first enroll in the Plan.
When your coverage ends, you will automatically be provided with a certificate of credible coverage. You also may request a certificate during the 2-year period following the date your regular or continuation coverage ends.
Continuation CoverageIf your (or your Eligible Dependent’s) medical, dental, and/or vision coverage ends because of a “qualifying event,” you (or your Eligible Dependent) will be a “qualifying beneficiary” under COBRA. This means that you (or your Eligible Dependent) can elect to continue your (or your Eligible Dependent’s) existing medical, dental, and/or vision coverage. This is called “continuation coverage.” A child born to, adopted by, or placed for adoption with you during your continuation coverage period is a “qualified beneficiary” too.
Your termination of employment (other than for gross misconduct) or reduction in hours is a “qualifying event” for both you and your Eligible Dependent. This means that if you or your Eligible Dependent lose coverage because of one of these events, you will receive a notice telling you that you can elect continuation coverage for up to 18 months. You must elect coverage within 60 days after the date of the notice. In certain cases, if you or your Eligible Dependent becomes disabled, the 18-month period may be extended to 29 months.
For your Eligible Dependent, a “qualifying event” also includes your death, divorce, or legal separation, or your becoming entitled to Medicare. Your child’s no longer being an Eligible Dependent (for example, reaching age 19 and not being a full-time student) also is “qualifying event” for your child. If one of these events occurs, you or your Eligible Dependent must notify us within 60 days after the event occurs, or your Eligible Dependent will not be able to elect continuation coverage. If we receive notice and the event causes your Eligible Dependent to lose coverage, your Eligible Dependent will receive a notice telling him or her that he or she can elect continuation coverage for up to 36 months. Coverage must be elected within 60 days after the date of the notice.
If continuation coverage is elected, you must pay premiums. The premiums will be 102% of the total premium amount (including both the employee and employer portions) for the coverage elected. The continuation coverage premium amount may be increased to 150% of the total premium amount if continuation coverage is extended from 18 months to 29 months due to a disability. Generally, premium payments are due on the first day of each month. If a premium payment is not received within 30 days of the first day of the month, continuation coverage will be terminated retroactively to the first day of the month. The first premium payment will be due within 45 days after continuation coverage is elected.
Legislative changes introduced in the American Recovery and Reinvestment Act (ARRA) included a provision to provide reduced COBRA premiums for “Assistance Eligible Individuals.” This legislation provides for a 65% reduction in premium for a maximum period of 9 months for plan members who experience a COBRA-qualifying event between September 1, 2008 and December 31, 2009. To be considered an “Assistance Eligible Individual,” plan members are required to meet all of the following requirements:
Ø You must lose coverage under this Plan as a result of an involuntary termination for reasons other than gross misconduct; and
Ø The loss of coverage must occur between September 1, 2008 and December 31, 2009; and
Ø You must timely elect to continue your benefits through COBRA; and
Ø You must not be eligible for Medicare; and
Ø You must not be eligible for coverage under any other group health plan, such as a health plan sponsored by a new employer or your spouse’s health plan.
For further information about ARRA or to determine whether you are an Assistance Eligible Individual, please contact the Claims Administrator. The provisions under ARRA are set to expire December 31, 2009.
Your (or your Eligible
Dependent’s) continuation coverage will end sooner than the maximum 18 (or 29 or
36) month period discussed above if any of the following happens: a premium is
not paid, coverage is obtained under another group health plan (or under
Medicare) after the COBRA election is made, or we stop providing medical,
dental, and/or vision coverage to our employees (or their dependents).
Medical Benefits
Overview of Medical BenefitsYou can choose medical coverage for yourself only or for yourself and your Eligible Dependents. The Plan uses the BlueCross© BlueShield© of Arizona (BCBSAZ) Preferred/Exclusive Provider Organization (PPO/EPO). A PPO/EPO is a group of hospitals, physicians, and other health care providers contracted to furnish medical care at negotiated rates. The PPO/EPO providers are listed as BCBSAZ "Preferred Care" and "Participating Only" providers. If you work in the Fredonia, Arizona area, you can also use the Health Management Network (HMN) of Utah PPO/EPO network.
Use of PPO/EPO providers is referred to as "In-Network" and use of non-PPO/EPO providers is referred to as “Out-of-Network.” To get In-Network services, you must use a doctor or hospital on the PPO/EPO provider list(s). You can select any doctor on the PPO/EPO provider list(s), and you don’t need a referral to see a specialist. Generally, Out-of-Network services are not covered under the Plan (see “Out-of-Network Benefits” under “Schedule of Medical Benefits” below for specific instances in which such services may be covered).
You will be provided, free of charge, a current directory of the BCBSAZ provider lists. If you live in Fredonia, Arizona, you will also receive the HMN provider list. To get In-Network services, select a provider from the directory(ies) or contact BCBSAZ at (800) 232-2345 or online at www.azblue.com to verify current status as a network provider. For Fredonia residents using the HMN list, contact HMN at (800) 448-3585.
If your PPO/EPO physician needs to send you to another physician or admits you to a hospital, be sure that you are referred to a provider that participates in the applicable PPO/EPO network.
(BlueCross© BlueShield© of Arizona, an independent licensee of BlueCross BlueShield Association does not provide administrative or claims payment services for Northern Arizona Council of Governments. NACOG has assumed all liability for claim payments. No provider network benefits are available outside of Arizona.)
Schedule of Medical Benefits
Individual Lifetime Maximum: $2,000,000 (Applies to all benefits under the Plan)
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Deductibles per Calendar Year: $500 Individual / $1,500 Family (Do not Cross Accumulate)
(All benefits shown at a percentage are subject to the above deductibles unless otherwise indicated.)
In-Network Benefits: (Available only through BCBSAZ or HMN (for Fredonia residents))
Physician Office
Visits $25 co-pay per visit
Chiropractic Care $25
co-pay per visit
($40 per visit payable; Max 30 visits per Cal Year)
Routine Physicals/Wellness $25
co-pay per visit (Max $500 per Cal Year)
Childhood Immunizations (up to age 6) 100%
Allergy Injections $0
co-pay (when not part of an Office Visit)
Outpatient Laboratory 100%
Outpatient X-ray 80%
Mammograms 80%
(deductible waived)
Urgent Care Center $40
co-pay per visit
Inpatient Hospital
- Phoenix/Tucson 100%
- All other Locations
80%
Inpatient Physician Visits 80%
Outpatient Hospital Emergency Room 80% (subject to
an additional $150 deductible; waived
if admitted)
Outpatient Surgical Facility 80%
Surgeon Fees
80%
Anesthesiologist
80%
Maternity
Inpatient
Hospital Charges
-Phoenix/Tucson 100%
-All Other Locations 80%
Pre & Postnatal Care $25
co-pay (Initial Visit Only)
Delivery
-Phoenix/Tucson
100%
-All Other Locations
80%
Ambulance Service 80%
(deductible waived)
Physical Therapy 80%
Home Health Care
80% (Max 60 visits)
Hospice Care
80% (Max 100 days)
Skilled Nursing/Rehab Facility 80%
Durable Medical Equipment 80%
Mental Health
Care/Substance Abuse:
Outpatient
$25 co-pay per visit
Inpatient 80%
Psychological Testing 80%
All Other
Eligible Expenses 80%
Out-of-Network Benefits: Not covered, except in the following instances:
• If you need emergency medical care while outside of the Plan’s PPO/EPO network(s) and the Plan determines that immediate attention was needed due to an unexpected accident or illness, the emergency medical care will be covered on the same basis as if provided In-Network.
• If you use an In-Network facility and an In-Network doctor and do not have a choice as to which anesthesiologist or radiologist is used, the services of an Out-of-Network anesthesiologist or radiologist will be covered on the same basis as if provided by an In-Network anesthesiologist or radiologist.
• If you believe there are no In-Network specialists who have the specific knowledge and training necessary to meet your medical needs, you may request prior approval from American Health Group to use an Out-of-Network specialist. If American Health Group (in its discretion) approves your request, the Out-of-Network specialist’s services that are provided after American Health Group’s approval will covered on the same basis as if provided by an In-Network specialist.
• In certain cases, an Out-of-Network facility may be approved for an organ transplant (see “Organ Transplants” under “Surgery & Anesthesia” below).
Out-of-Pocket Maximum: The out-of-pocket maximum is $2,000 per calendar year. After you incur the maximum in out-of-pocket expenses, eligible charges will be paid at 100% for the balance of the calendar year. Deductibles and co-pays are not included in determining whether you have incurred the maximum in out-of-pocket expenses.
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PRESCRIPTION DRUG CARD: "Walgreens Health
Initiatives" Co-pays
Retail: up to a 30 day supply
$10 Generics
$25 Preferred Drugs
$50 Non-Preferred
Mail Order: up to a 90 day
supply $10 Generics
$50 Preferred Drugs
$100 Non-Preferred
Advantage 90 Program: up to 90 day supply at retail
$14 Generics
$62.50 Preferred Drugs
$125 Non-Preferred Drugs
Coverage for Proton Pump Inhibitors (PPIs) are excluded.
Special Rights Following MastectomyThe Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires that a group health plan make certain benefits available to participants who have undergone mastectomies covered by the Plan. This means that if you have had or are going to have a mastectomy, you may be entitled to certain benefits under the WHCRA. For individuals receiving 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 was performed;
• surgery/reconstruction of the other breast to produce a symmetrical appearance;
• prostheses; and
• treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under the Plan (see “Schedule of Medical Benefits” above). If you would like more information on WHCRA benefits, contact the Human Resources Department.
Mother’s and Newborn’s Rightsroup health plans and health insurance issuers generally may not, under federal law, 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 cesarean section. However, federal law does not prohibit the mother’s or the newborn’s attending provider, after consultation 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 from the plan or insurer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable).
Eligible Medical Expenses
The following medical expenses are covered under the Plan, subject to
applicable co-payments, deductibles, maximums, limitations, exclusions, and
other conditions explained in the plan document and/or this Summary.
Hospitals, Facilities & Ambulance
• Emergency Room: Charges by the hospital for the use of the hospital
emergency room or free standing urgent care center for appropriate medical
charges necessitated by an acute medical emergency. Charges are subject to a
separate Emergency Room Deductible as indicated in the Schedule of Medical
Benefits, unless the patient is admitted to the hospital.
• Hospice: Charges for hospice care provided by licensed hospice and certified to receive payment under Medicare, when it has been determined that the covered person has less than 6 months to live. The care must be certified by the attending physician, documenting the necessity of such care when traditional medical treatment and cure-oriented services are no longer medically appropriate due to the covered person's terminal condition. The plan of hospice care must be renewed in writing by the attending physician every 30 days. Hospice benefits are limited to 100 days and end if the terminal illness enters remission.
• Inpatient Hospital: Inpatient hospital charges for semi-private room and board, intensive care and miscellaneous hospital services directly related to the treatment of the injury or illness that necessitated the confinement. Charges for a private room are eligible only if prescribed by a physician and the private room is medically necessary.
• Licensed Birthing Center: Charges by a freestanding or hospital based, public or private institution, other than private offices or clinics of physicians, which is licensed by the State as a birthing center or is associated with a licensed hospital and meets the official requirements of the State Department of Health.
• Skilled Nursing Facility: Charges made by a skilled nursing facility or extended care facility, provided the confinement is certified as medically necessary by the attending physician and the care is not of a custodial nature. Limited to 60 days per calendar year.
• Surgical Facility: Charges by a hospital based or freestanding ambulatory/surgical facility.
• Urgent Care Facility: Services rendered at an urgent care facility when immediate medical attention is necessary.
• Licensed Professional Ambulance Charges: Charges for: a) ground ambulance to the nearest appropriate hospital within 24 hours of an accident or the sudden onset of severe symptoms of an illness; b) transfer by ground ambulance to the nearest hospital with the necessary equipment, staff and facilities to treat the patient's condition, if treatment cannot be performed at the initial hospital; c) ground ambulance service from the hospital to the covered person's permanent place of residence will be covered, if medically necessary, as determined by the Plan; or d) transport by air ambulance will be covered as described in a & b above but only when medically necessary due to a life threatening condition. Air ambulance services for facility to facility transports must be authorized by Medical Transport Logistics (MTL).
Surgery & Anesthesia
• Anesthesia:
Charges by a licensed anesthesiologist for the administration of anesthetics,
pre- and post-operative visits and the administration of fluids and/or blood
incidental to the anesthesia or surgical procedure.
• Assistant Surgeon: Charges for an assistant surgeon when medically required. If the assistant surgeon is a BlueCross BlueShield of Arizona provider, the eligible charge amount will be twenty percent (20%) of the surgical allowance of that assistant surgeon’s BCBSAZ contract. If the assistant surgeon is not a BCBSAZ provider, and the assistance is an MD or DO, the eligible charge amount will be up to 25% of the allowable charges for the surgeon. If the assistant surgeon is a non-BCBSAZ Registered Nurse First Assistant (RNFA), Certified Surgical Assistant (CSA) or a Physician's Assistant (PA), the eligible charge will be up to 15% of the allowable charge for the surgeon. The services of a standby surgeon will only be covered when: a) a clear medical necessity exists, and b) the standby surgeon is gowned, scrubbed, and physically present in the surgical suite.
• Oral Surgery: Charges for oral surgery for the removal of tumors or cysts, or for the restoration of sound natural teeth or the alveolar processes due to an accidental injury (restoration made to a functional level). Charges must be rendered within 6 months of the date of the accident unless medically indicated that treatment be delayed. If treatment is delayed, charges will only be eligible if coverage is still in force at the time the treatment is rendered. Facility charges and general anesthesia related to covered oral surgery will only be eligible if prescribed by a physician and medically necessary.
• Organ Transplants: Charges for the following non-experimental human to human organ or tissue transplants: Bone Marrow; Kidney; Cornea; Liver; Heart; Lung; or Heart/Lung. To be covered, a) the covered person must be a likely candidate for a successful outcome of the procedure; b) the covered person must properly pre-certify and maintain case management services throughout the course of the transplantation and post transplantation period as directed and coordinated by the Plan's utilization review company; and c) the procedure must be performed at an In-Network facility known to have an effective program for doing such procedure. If there isn’t an In-Network facility that is equipped to perform the transplant, an Out-of-Network facility may be eligible if approved in advance by the Plan and the reinsurance carrier. Charges associated with the donor for the removal of the organ, and/or the procurement, acquisition, or transportation of the organ will be covered, subject to the recipient’s individual benefit levels and plan maximums. Charges related to the donor for screening and testing are not covered expenses under the Plan.
• Reconstructive Surgery: Charges for reconstructive surgery that is: a) required as the direct result of an accidental injury or an infection or disease of the involved part; b) necessary for the correction of congenital abnormalities which result in a functional defect; or c) necessary for post mastectomy or post oncology treatment. Eligible charges will include surgery and reconstruction of the other breast to produce a symmetrical appearance and prosthesis and treatment of any physical complications at all stages of mastectomy, including lymphedemas.
• Second Surgical Opinion: Charges for a second surgical opinion if required and authorized by the medical review company. The medical review company will direct the Covered Person to a surgeon that is not associated with the original Physician and who specializes in treating the specific surgical problem.
• Surgery: Charges by a physician for surgery performed at a hospital, a licensed surgical center or in the office. In the case of multiple surgeries performed through the same incision, the maximum allowable expense shall be equal to the usual, customary, and reasonable amount for the procedure with the greatest scheduled amount. Additional allowances (modifiers) may be given when the additional surgeries add significant complexity to the surgical session. If during the same surgical session multiple surgeries are performed through separate incisions, the allowable expense shall be calculated at the full usual, customary, and reasonable amount of the primary procedure, and at 50% of the usual, customary, and reasonable amount of each of the lessor procedure(s) that are through their own separate incision(s).
Medical & Physician Services• Allergy Testing & Injections: Charges for initial allergy testing, and the cost of the resultant serum preparation and its administration, when rendered by a physician, or in the physician's office. When the allergy injection is part of an office visit, the co-pay applies, and if the covered person is only receiving the allergy injection, the charge for the injection is paid at 100%. Injections of food allergy antigens and the like are not eligible expenses. The allowance for antigens will be based on a 3-month supply and a per vial cost.
• Chiropractic: Charges for chiropractic care and spinal manipulations for the correction of structural imbalance, distortion, misalignment or subluxation of or in the vertebral column, by manual or mechanical means and the necessary adjunctive modalities (hot, cold therapy etc). Eligible charges are limited to $40 per visit and 30 visits per calendar year.
• Dialysis: Charges for dialysis.
• Home Health Care: Charges for home health care/home infusion services rendered by a licensed home health care agency which a physician has prescribed and which is determined by the Plan to be medically necessary and the most appropriate care. Mileage charges may be eligible if the covered person resides in a remote area that does not have a local home health care agency. Charges are subject to a maximum of 60 visits per calendar year. A visit by a representative of a Home Health Agency of four (4) hours or less shall be considered as one (1) Home Health Care visit. Charges for custodial care, mental health care, or substance abuse or chemical dependency treatment are not eligible under this provision.
• Pathology & Radiology: Charges by a laboratory, a pathologist or a radiologist for diagnostic or curative services related to an illness or injury, when ordered by a physician. Charges for routine screenings are covered up to the Wellness benefit shown in the Schedule of Medical Benefits.
• Physician: Charges by a physician for medical care either in the hospital, emergency room, office, clinic or other health care facility. The services of a Physician's Assistant (PA) or of a Nurse Practitioner will be eligible provided they are operating under the direct supervision of a physician.
• Rehabilitation Services & Physical Therapy: Charges for rehabilitation services including physical therapy, physio-therapy, speech therapy and occupational therapy for short term progressive rehabilitation therapy, provided it is mandated by the disability and is not of a maintenance nature. The rehabilitation therapy must be ordered by and under the supervision of a Doctor of Medicine, Doctor of Osteopathy, or by a Doctor of Podiatry for the area of the body that is within the scope of his or her license, and rendered by a physician or a licensed/registered therapist. Benefits will cease if treatment becomes of a maintenance or custodial nature.
• Speech Therapy: Charges made by a qualified speech therapist for restoration of normal speech or to correct dysphasgic or swallowing disorders, when the loss or impairment is due to an injury, illness or surgery. The therapy must be prescribed by a qualified physician. Speech therapy is not covered for the correction of stuttering, stammering, myofunctional or conditions of psychoneurotic origin.
• Wellness Services: Charges for routine physicals, routine laboratory tests and x-rays, routine mammograms, routine well child care, and flu shots. Benefits payable are subject to a maximum benefit of $500 per calendar year. Routine childhood immunizations for children up to age 6 are not subject to the annual wellness maximum.
Maternity & Family Planning• Abortions: Charges incurred for a medically required abortion for a covered person when the continuation of the pregnancy would be life threatening to the mother.
• Contraception: Charges for contraceptive devices, insertion and removal of I.U.D.s, the cost for a diaphragm and its fitting, or medication (birth control pills and depo-provera shots) for birth control purposes.
• Midwife: Charges made by a Certified Nurse Midwife (CNM) for obstetrical or well woman care that is within the scope of his or her license in the state in which he or she is licensed.
• Newborns: Charges incurred at a hospital for "routine" newborn care, including charges for a routine in-hospital exam by a pediatrician and routine circumcisions will be covered as part of the mother's maternity claim. Any charges incurred by the newborn for other than routine care or for any routine care after discharge will only be covered if dependent coverage is in effect, or is added within 31 days of the date of birth. These charges are subject to the newborn's own maximums and deductibles.
• Pregnancy: Charges incurred as a result of pregnancy for pre- and post-natal care and delivery provided coverage is in effect at the time the actual charges are incurred (i.e., at the time of delivery). Eligible expenses include routine lab work, 1 routine ultrasound during the course of pregnancy, and $600 towards the cost of a routine epidural.
• Sterilizations: Charges incurred for elective or medically required sterilizations. When a vasectomy is elected, only the physician's charge for the surgery in his or her office will be covered. Facility charges for vasectomies are not covered.
Medications, Equipment & Supplies• Blood: Blood transfusion services, including the cost of blood and blood products, to the extent they are not replaced or donated through the operation of a blood bank or otherwise.
• Bras: Charges for prosthesis bras (up to 2 per year) and the related postmastectomy prosthetic devices.
• Contact Lenses: Charges made for the initial pair of contact lenses as prescribed by a physician when required immediately following cataract surgery.
• Corrective Appliances: Charges for corrective appliances including the original fitting, when ordered by a physician and medically necessary. Charges will only be allowed for the standard model of the corrective appliance. The rental or purchase of a corrective appliance is at the option of the Plan, and rental is payable only up to the allowed purchase price. Charges will be allowed for replacement, adjustment and servicing of the appliance when necessary due to the growth of a covered child, or when the appliance has exceeded its maximum life expectancy.
• Durable Medical Equipment: Charges for necessary durable medical equipment (DME) as prescribed by a physician. Charges will only be allowed for the standard model of the particular piece of equipment. The rental or purchase of DME is at the option of the Plan, and rental is only payable up to the allowed purchase price.
• Medications: Charges for Covered Prescription drugs and medicines, obtainable only upon a Physician's written prescription, and prescribed for treatment of a covered illness or injury. Most prescriptions are purchased with the Rx card issued by the Plan. Covered Persons present their Rx card to the Pharmacist and pay the co-pay amount indicated in the Schedule of Benefits. Medications that can be purchased over-the-counter are not eligible.. Coverage for Proton Pump Inhibitors (PPIs) are specifically excluded from Rx coverage.
• Oxygen: Charges for oxygen and for the rental or purchase of the equipment to use it. Rental charges are only eligible up to the purchase price.
• Supplies: Charges for the following non-durable (disposable) supplies: a) sterile surgical supplies required following a covered surgery; b) insulin syringes and test strips for diabetics; c) supplies required to operate/use durable medical equipment or corrective appliances; d) supplies required for use by skilled home health or home infusion personnel, but only for the duration of their services; and e) anti-embolism garments (e.g., Jobst) up to 3 per calendar year.
• Orthopedic Shoes & Orthotics: Charges for medically necessary orthopedic shoes and other related supportive appliances, including their replacement once in each 12-month period, or, if under 19 years of age, once in each 6month period if necessitated by the child's growth. Orthotics will only be covered when ordered by a M.D. or D.P.M. and dispensed by a certified orthotics laboratory.
Mental Health Care & Substance Abuse• Inpatient Treatment: Facility charges for inpatient or residential treatment of mental and nervous disorders, chemical dependency or substance abuse when care is received at a licensed hospital or a licensed treatment facility. Alternative outpatient facility/day programs/Intensive Outpatient Programs (IOP) may be eligible under the inpatient benefit when provided in lieu of inpatient care and approved by the Plan.
• Outpatient Treatment: Outpatient treatment for mental health care, treatment of chemical dependency or substance abuse or family counseling will be eligible when rendered by a licensed Psychiatrist; a licensed Psychologist; one of the following licensed counselors: a Licensed Professional Counselor (LPC), a Licensed Clinical Social Worker (LCSW), a Licensed Marriage and Family Therapists (LMFT), or a Licensed Independent Substance Abuse Counselor (LISAC), a Psychiatric Nurse Practitioner (PSYNP), or by one of the following counselors, provided that the counselor is employed by and working under the direct supervision of a licensed Psychiatrist or a licensed Clinical Psychologist: a Certified Professional Counselor (CPC), a Master Social Worker (MSW), a Master Science Nurse (MSN), a Master of Arts in Guidance & Counseling (MA), a Master of Education in Guidance & Counseling (MED), or a Master in Counseling (MA). Psychological testing and neuropsychological testing are covered only if it is mandated by the condition and is pre-certified by the Plan.
Case Management &
Pre-Certification
Case Management In certain
complex medical situations, American Health Group (AHG) will provide case
management services. Case management services are designed to provide a
proactive, systematic process of coordination of health care services that are
otherwise covered (i.e., not excluded) under the Plan. If case management
services are provided, a case manager will be assigned to work with the patient
and the physician to coordinate an effective treatment plan.
Pre-Certification Pre-certification helps ensure appropriate health care and avoids unnecessary expenses. The following must be pre-certified:
• Diagnostic tests over $1,000
• Surgical procedures over $1,000
• All non-emergency hospital admissions (excluding maternity)
• Home health care and home infusion therapy
• Skilled nursing facilities and hospice care
• Psychological and neuropsychological testing
IMPORTANT: Pre-certification of a procedure does not guarantee benefits. All benefit payments are determined by AEI in accordance with the provisions of the Plan.
In case of a non-emergency: To pre-certify, contact AHG before the admission or procedure. AHG will review the request for services and contact the physician for any records or additional information necessary for AHG to evaluate the need for services. Benefit eligibility for the pre-certified procedures must be verified with AEI prior to completing services. Once a pre-certification is received, it is valid for 90 days.
In case of an emergency: Notify AHG by telephone within 48 hours of the procedure or the admission.
If services are not pre-certified, the services may not be covered. If they are covered, you will have to pay an additional deductible of $300, which will not count toward your out-of-pocket maximum or calendar year deductible.
Pre-certification is a pre-service claim (or an urgent care claim if your life/health is in jeopardy) (see “Pre-Service Claims” under “Types of Claims”). If there is any reduction or elimination of pre-certified services (before the pre-certified time or number of treatments ends), this will be a claim denial, and you will be notified in advance and will have the right to request a review of the denial (see “Claims Procedure” and Appeals Procedure”). A request to extend pre-serviced services generally is a pre-service claim. If, however, your claim is an urgent care claim, and you request extension of pre-certified services at least 24 hours before the services are scheduled to end, your claim will be decided within 24 hours. If your proposed treatment is not approved, you can appeal that decision (see “Appeals Procedure” for more information).
Second Opinions Before approving a requested surgical procedure, AHG may require a second opinion. If a second opinion is required, AHG will give you the name of one or more physicians who can provide the second opinion.
Limits & Exclusions
The following items are not covered by the Plan (even if medically
necessary or recommended by a physician):
• Services and supplies which are not medically necessary, as determined by the Plan, or are not necessitated as the result of existing symptoms of an illness or injury, or are not considered the standard medical treatment for the diagnosed condition, except as otherwise covered as Wellness Services.
• Charges incurred prior to a covered person's enrollment date, or after the covered person's coverage ends, and charges incurred in connection with pre-existing conditions during the applicable pre-existing condition exclusion period.
• Medical care, services or supplies which do not come within the Plan’s definition of eligible expenses and/or are not rendered by an eligible provider of service as defined by the Plan.
• Expenses associated with complications of a noncovered condition, illness, procedure or service, except for expenses associated with medical complications arising from an abortion which will be covered.
• Any charges in excess of rates negotiated between any organization and the physician, hospital or other provider of services, whether the plan is a primary or secondary payor.
• Charges which exceed any Plan benefit limitation or maximum allowable benefit.
• Any services for which a charge would not have been made in the absence of this coverage; or portion of a charge that is higher than the amount that would have been charged in absence of this coverage.
• Charges, or a portion of a charge, for services or supplies that are discounted or reimbursed by a refund or rebate.
• Charges for an illness or injury deemed to have arisen out of or in the course of doing any work for wage or profit whether or not there was Worker’s Compensation coverage for such claim, and whether or not the illness or injury has been reported in accordance with the Worker's Compensation rules. No such claim shall be payable under the Plan unless the injury or illness has been adjudged as non-occupational by the appropriate Worker's Compensation Board.
• Treatment received for an illness or injury sustained as a result of being engaged in an illegal occupation, sustained while incarcerated, or sustained during the commission of, or the attempted commission of a crime, an assault, felony, misdemeanor or any other illegal act whether or not there is a criminal charge or a conviction of a crime.
• Services received or supplies and medication purchased outside the United States unless the charges incurred are a result of a life threatening emergency or accidental injury that occurs while traveling outside the United States.
• Charges incurred for preparing medical reports, itemized bills, or claim forms. Expenses for broken appointments, telephone calls, photocopying fees, mailing, shipping or handling expenses.
• Charges incurred due to a court ordered treatment or hospitalization unless a clear medical necessity also exists.
• Services rendered by an immediate family member, whether the relationship is by blood or law, or by any person who regularly resides in the covered person's home.
• Examinations, vaccinations, inoculations or immunizations related to employment, premarital or pre-adoptive requirements, issuance of insurance, obtaining a license, judicial or administrative procedures, medical research or travel to foreign countries.
• Examinations or tests not incidental to or necessary to diagnose an injury or illness, except for routine care otherwise specifically covered as a Wellness Service.
• Charges or treatment provided as a benefit under a program of the United States Government or State agency or political subdivision, including but not limited to active duty in the armed forces, Medicare, Medicaid, CHAMPUS or any treatment paid for by any governmental program, unless the covered person is legally required to pay.
• Services received in a U.S. Department of Veterans Affairs (VA) hospital or VA facility on account of a military service-related illness or injury.
• Treatment of an illness or injury resulting from an act of war (whether declared or undeclared), invasion or aggression, or any atomic explosion or release of nuclear energy (except when used solely for the purpose of medical treatment).
• Treatment of an illness or injury caused by participating in a civil insurrection or a riot.
Additional Limits &
Exclusions
The following items also are not covered by the Plan (even if
medically necessary or recommended by a physician). This list is in alphabetical
order, but you should review all limits and exclusions because the wording of a
particular excluded item may place it in a location other than where you might
expect to find it.
• Abortions & elective termination of pregnancy, unless the mother’s life would be endangered if the pregnancy were allowed to continue.
• Acupuncture.
• Adoption charges and/or charges incurred by a surrogate mother.
• Assistant surgeon charges when the need for an assistant is not documented.
• Assistive & self-help devices which do not serve a primary medical purpose and instead ease the performance of activities of daily living, including but not limited to feeding utensils, reaching tools, devices to assist with dressing and undressing, etc.
• Autologous blood donations, unless the blood is actually used during a scheduled surgery.
• Autopsies, unless required by the Plan.
• Biofeedback, hypnosis, or behavior modification therapy (i.e., stress management, weight reduction, nutrition classes, etc.).
• Breast reconstruction (except as otherwise covered under Reconstructive Surgery) or charges for breast augmentation or breast reduction. Charges related to the removal of breast implants inserted for cosmetic purposes are not eligible regardless of the reason for removal.
• Chelation therapy, except when necessary for treatment of heavy metal poisoning.
• Cochlear implants, hearing aids, hearing examinations, or examination or surgery relating to hearing implants, except when required for surgery to place tubes in the ear or for the initial purchase of a hearing aid when necessary due to a hearing loss that resulted from a performed surgery that was covered under the Plan.
• Comfort items & cosmetic items; Charges incurred for services, supplies or surgery which are primarily for personal comfort or primarily to improve or enhance personal appearance, including but not limited to, collagen injections, botox injections, sclerotherapy, liposuction, tattoos or tattoo removal.
• Cosmetic surgery, plastic surgery, or reconstructive surgery or any complications thereof, except as otherwise covered under Reconstructive Surgery.
• Counseling charges incurred for career, sexual, social adjustment, financial or religious reasons.
• Custodial care charges made by an institution or part thereof which is primarily a place for rest, the aged, a hotel, health spa, fitness or weight reduction resort or similar institution or childcare, homemaker services or maintenance care.
• Dental procedures or dental treatment, except as otherwise covered as oral surgery or as dental benefits for individuals enrolled in dental coverage.
• Developmental disorders; Charges made by a special education facility, tutor, behavior specialist or provider of any kind for testing or treatment of developmental disorders or learning disabilities. Office visits to monitor the medications for Attention Deficit Disorders (ADD and ADHD) will be covered.
• Disposable (non-durable) supplies, including but not limited to diapers, incontinence pads and bandages, except as otherwise covered as Supplies.
• Education expenses for job training.
• Elevators, chairlifts or other modifications to home, stairs or vehicles.
• Exercise; Charges incurred or related to health club/exercise/gym memberships, aerobic and strength conditioning, back schools or back strengthening programs, massage therapy, Rolfing, and exercise equipment rental or purchase.
• Experimental; Charges for services, procedures, equipment or supplies which are considered experimental or investigational (as defined in the Plan).
• Eye surgery (Kerato-refractive surgery) to correct nearsightedness or farsightedness and/or astigmatism, including but not limited to Radial Keratotomy and keratomileusis surgery and refractive keratoplasties and LASIK surgery.
• Genetic services rendered during pregnancy (or in anticipation of a pregnancy), including tests and procedures performed for the purpose of detecting, evaluating or treating chromosomal abnormalities or genetically transmitted characteristics, except alphafetoprotein analysis.
• Hair loss; Services or supplies for the prevention or restoration of natural hair loss (i.e., Rogaine, Minoxidil), or charges for hair transplants or wigs.
• Health Maintenance Organization (HMO) providers when services are rendered to a covered HMO plan member.
• Hearing aids (see also cochlear implants above).
• Holistic services, supplies or accommodations provided in connection with holistic or homeopathic treatment or medicine.
• Infertility; Charges related to the treatment of infertility, infertility drugs, artificial insemination, in-vitro fertilization, embryonic transfer, sperm banking or any other similar procedure (however, charges to diagnose the condition of infertility will be considered an eligible expense).
• Learning disabilities; Charges (including mental health care) related to treatment or testing of learning disabilities, developmental disorders, dyslexia, autism or mental retardation or any similar conditions.
• Massage therapy or Rolfing.
• Maintenance rehabilitation therapy or therapy for coma stimulation inpatient or outpatient.
• Medical students, interns or residents.
• Medications; Charges for experimental or non-prescription medications, charges for prescriptions to be used for an application that has not been approved by the FDA or medications that can be purchased over-the-counter. Non-smoking aids, drugs for cosmetic purposes, weight control drugs, proton pump inhibitors, or fertility agents. All eligible prescriptions are provided through the prescription drug card.
• Myofunctional therapy or the treatment of tongue thrusts.
• Naturopathic treatment or services rendered by a Naturopath.
• Occupational therapy and supplies, except during an inpatient hospital confinement, as included in home health care services, or for short term progressive rehabilitation following an acute illness or injury.
• Organ or tissue transplants (except as otherwise covered as Organ Transplants), including insertion or maintenance of an artificial heart or organ and charges for artificial, experimental or non-human body organs or tissue transplants.
• Orthognathic surgery.
• Orthotics, except as otherwise covered as Orthopedic Shoes or Orthotics.
• Pediatrician charges for services as a standby pediatrician during childbirth unless a high risk factor was indicated during the covered pregnancy.
• Personal comfort items or devices which do not meet the Plan’s definition of durable medical equipment or corrective appliances, including but not limited to air conditioners, air purifiers, dehumidifiers, water purification systems, waterbeds, airbed systems, cervical pillows, whirlpools, spas and the like.
• Personal service items while confined in a hospital or health care facility (i.e., guest meals, television, telephone, etc.).
• Private duty nursing services while hospital confined.
• Prosthesis replacement, unless necessitated by the growth of a child or the prosthesis has exceeded its maximum life expectancy.
• Reversal surgery of any kind.
• Sexual dysfunction or sexual inadequacy, including but not limited to sex change operations, medications, penile prosthetic implants or similar devices.
• Sleep disorders; charges related to the diagnosis and treatment of sleep disorders, except in the case of sleep apnea.
• Smoking cessation programs, aids, devices or drugs (i.e., Nicorette and Nicoderm).
• TMJ; charges for surgical or non-surgical care or treatment related to Temporomandibular Joint Dysfunction or Syndrome (TMJ), craniomandibular disorders, reconstruction of the maxilla or mandible for micrognathism, or retrognathism or orthognathic surgery.
• Transportation charges, except as otherwise covered as Licensed Professional Ambulance Charges.
• Travel charges (transportation, lodging, meals and related expenses) by a covered person, a physician or any healthcare provider, except as otherwise covered as Home Health Care.
• Vision; charges incurred for diagnosis or treatment relating to eye refractive error, orthoptic or visual training, vision therapy, testing for visual acuity, field charting or for eyeglasses or contact lenses or for the fitting of such items, except as otherwise covered as vision benefits for individuals enrolled in vision coverage.
• Vitamins, nutritional supplements, minerals, diets, foods, infant formula and naturopathic or homeopathic services and/or substances whether prescribed by a physician or purchased over-the-counter.
• Vocational or educational training services, supplies or materials.
• Weight Control & Obesity; charges incurred for the care and treatment of obesity or primarily for weight control, including weight control drugs, supplies, supplements, substances, weight reduction programs or surgery, including but not limited to bariatric surgery, gastric and/or intestinal bypass or gastric balloon implants. Gastric stapling is also not covered unless the covered person: a) is confirmed to be morbidly obese by two legally qualified covered physicians; b) has been 100 pounds over ideal weight for 5 or more years; c) has tried weight reduction diets and/or medications under a physician's care and failed to maintain weight loss and can provide proof of same; and d) has underlying medical problems such as arthritis, hypertension, diabetes, or a strong family history of same, which present a life threatening situation.
Pre-Existing ConditionsUnder the Plan, a “pre-existing condition” is a condition for which medical advice, diagnosis, care, prescribed drugs or medication, or treatment was recommended or received during the six-month period immediately preceding your “enrollment date.” Your “enrollment date” is the date you become covered under the Plan (or your date of hire, if earlier and you enrolled when first eligible). You are a “late enrollee” if you do not enroll when first eligible or during a special enrollment. Pregnancy and genetic information will not be considered pre-existing conditions.
For 12 months (or 18 months for a late enrollee) from your “enrollment date,” any services or treatment you receive for a pre-existing condition will not be covered by the Plan. This 12-month (or 18-month) period will be reduced by the number of months you were covered under another health plan if you did not have a break in coverage of more than 63 consecutive days and you provide a certificate of creditable coverage. You can get a certificate from your last employer, the administrator or the insurance company with whom you previously had health care coverage.
When you first seek treatment of a pre-existing condition, send your certificate of creditable coverage to AEI. Your certificate must include your name and social security number. AEI will send you a written notice letting you know if the 12-month (or 18-month) period will be reduced and by how many months it will be reduced.
If your claim would be denied as a pre-existing condition, you will have 90 days to provide a certificate of credible coverage. If you do not provide a certificate within 90 days, your claim will be denied. If you later provide a certificate, your claim will be reviewed to determine if it must still be denied as a pre-existing condition.
No pre-existing condition limit will be imposed for newborn or adopted children under the age of 18 who are adopted or placed for adoption and who are enrolled in the Plan within 31 days of the birth or adoption or are enrolled in the Plan following coverage under another health plan without a break in coverage of more than 63 consecutive days.
Prescription Drug
Program
When you enroll in medical coverage under the Plan, you’re enrolled
in the Prescription Drug Program. To use the Program, go to a participating
pharmacy or use the Walgreens Health Initiatives’ mail order program. To find a
participating pharmacy near you, contact Walgreens Health Initiatives at (800)
207-2508. Your copay will depend on the level of prescription (see “Schedule of
Medical Benefits” above). You will generally pay the lowest copay for any
generic drug, a mid-level copay for cost-effective, preferred brand-name drugs,
and the highest copay for non-preferred brand-name drugs.
Dental Benefits
Overview of Dental
Benefits
You can choose dental coverage for yourself or for yourself and your Eligible
Dependents. If you enroll in dental coverage, you’ll be reimbursed for eligible
dental expenses that you incur, subject to the conditions, limitations and
exclusions discussed below. You can go to any licensed dentist. Submit your
claim for reimbursement to AEI.
Schedule of Dental
Benefits Dental Deductible: (amount you must pay)
Individual Deductible per Calendar Year
$ 50
Family Deductible per Calendar
Year
$150
Percentages Payable: (only payable after
deductible met)
Preventive Care (not subject to
deductible) 100%
Restorative
Care
80%
Routine
Extractions
80%
Endodontics
80%
Periodontics
80%
Oral Surgery
80%
Prosthodontic /
Prosthetics 50%
Orthodontics*
50%*
*If dental coverage is not elected within 31 days of when first eligible,
there will be a 24-month waiting period for orthodontics coverage
(i.e., no orthodontics coverage during the first two years of dental
enrollment).
Dental Benefit Maximums: (maximum amount
that the Plan will pay)
Maximum Benefit Payable per Calendar Year
$1,250 per person
Lifetime Orthodontic
Benefit $1,500 per
person
Covered Dental
Expenses
The following dental expenses are covered under the Plan, subject to
applicable deductibles, maximums, limitations, exclusions and other conditions
explained in the plan document and/or this Summary:
• Diagnostic and Preventive Service: Charges incurred to evaluate the conditions existing and the procedures or techniques to prevent the occurrence of dental abnormalities or disease. Diagnostic services provide for the necessary examination and x-ray procedures to assist the dentist in evaluating the conditions existing and the dental care required. Preventive services provide for procedures necessary to clean, scale and polish teeth and apply fluoride.
• Routine oral examinations and prophylaxis / cleanings (limited to 2 per calendar year).
• Topical fluoride treatments (to age 19)
• Full mouth and panorex x-rays (limited to 1 set in a 36 month period) and bitewing x-rays (limited to 1 set per calendar year).
• Pallative treatment and emergency care to relieve pain when no other dental treatment is given. If other treatment, other than x-rays, is given, the amount of benefits paid for the pain care will be based on the category of that treatment.
• Sealants on unrestored primary bicuspids and molars (to age 19)
• Restorative Services: Charges incurred to restore teeth to normal contour and function. Fillings: amalgam, synthetic, porcelain, plastic or composite materials.
• Endodontic Services: Charges incurred for the necessary examinations and procedures for diagnosis and treatment of diseases of the tooth pulp and/or infections of the root canal and periapical area; pulp therapy and root canal treatment.
• Periodontic Services: Charges incurred for the necessary examinations and procedures for diagnosis and treatment of the periodontium. The periodontium is collectively the tissue that surround and support the teeth (including the gingiva, cementum, periodontal membrane, and the supporting alveolar bone). Treatment for disease of gingival tissue or alveolar supporting structures of the mouth, including periodontal surgery and full mouth debridement.
• Surgical periodontal treatment is limited to once in a 24-month period for each quadrant.
• Crown lengthening or single tooth gingivectomy are allowed once in conjunction with crown preparation.
• Periodontal Prophys are limited to once every 6 months, not to exceed 2 per calendar year.
• Non-surgical periodontal treatment is limited to once per quadrant every 24 months.
• Occlusal adjustments, only in connection with periodontal surgery.
• Prosthodontic Services: Charges incurred for the necessary procedures or techniques concerned with the restoration and replacement of teeth. Dental prostheses may be either fixed or removable.
• Crowns: three-quarter, full and stainless steel.
• Charges for fixed bridges, Maryland bridges and full and partial dentures. Temporary partial dentures are covered only when anterior teeth are missing, and temporary full dentures are not covered.
• Porcelain, composite, or gold inlays and onlays.
• Charges for adjusting, relining, re-basing or repairing bridges or dentures and re-cementing inlays, onlays, crowns, or bridges.
• Space maintainers due to premature loss of posterior primary teeth (to age 14). Anterior space maintainers are not covered.
• Initial placement of bridges, or full or partial dentures (charges will be considered “initial placement" only if they are not replacing an existing bridge or denture) are covered provided:
• Placement is due to the extraction of one or more natural, injured or diseased teeth;
• Placement of bridge or denture includes replacement of extracted tooth; and
• Bridge or denture is placed within 12 months after the extraction.
• Replacement of an existing fixed bridge or a full or partial denture are covered provided:
• Prosthetic appliance to be replaced was placed more than 5 years ago and cannot be made satisfactory; and the covered person was eligible under the Plan a minimum of 12 months; or
• Addition of teeth is needed to replace 1 or more natural teeth extracted while the covered person was eligible under the Plan; and the addition of teeth is completed within 12 months after the date of the extraction(s); or
• Replacement of existing fixed bridge or denture is due to an accidental injury requiring oral surgery; and the replacement is completed within 12 months after the event.
• Implants are only payable up to the benefit allowed for a bridge or partial denture (whichever is less).
• Replacement of a denture is not covered if such replacement occurs in a period which is less than 5 years from the date of initial placement unless:
• Such replacement is necessary due to the initial placement of an opposing full denture or extraction of natural teeth; or
• The denture is a stayplate or a similar temporary partial denture, and is being replaced by a permanent denture; or
• The denture, while in the oral cavity, has been damaged beyond repair as a result of an injury that occurs while the individual is covered under the Plan.
• Oral Surgery: Charges incurred for the necessary examinations, x-rays and procedures for treatment by extraction or other oral surgery not covered under periodontic services. Provides the necessary procedures for extractions and other oral surgical procedures including impacted teeth and including pre- and postoperative care. Anesthesia in conjunction with covered oral surgery procedures (not allowed for simple extractions).
• Orthodontic Services: Subject to the separate orthodontic lifetime maximum, charges incurred for the detection, and active treatment and appliance for the correction of abnormalities of the teeth and malocclusion.
• Active course of treatment shall mean any services for diagnostic casts, x-rays, records, tooth extraction or the placement of active orthodontic appliances. The active course of orthodontic treatment is the period which begins when the first orthodontic service is performed and ends when the last active appliance is removed.
• Payments for active orthodontic treatment will be processed on a monthly basis prorated over the total period of the orthodontic treatment plan.
• The orthodontic benefit maximum for a covered person for any one course of treatment will include the charges incurred for diagnosis, evaluation, pre-care and x-rays.
Limits & ExclusionsThe following items are not covered under the Plan (even if medically necessary or recommended by a dentist):
• Items excluded from medical coverage (see “Limits & Exclusions”, “Additional Limits & Exclusions” and “Pre-Existing Conditions” under “Medical Benefits” above).
• Analgesia, sedation or hypnosis for relief of anxiety or apprehension.
• Anesthesia, except as specified for oral surgery.
• Appliances to increase vertical dimension or to restore or alter occlusion for cosmetic or non-cosmetic purposes, except as covered under orthodontia.
• Assignment of dental benefits to a provider outside of the United States.
• Charges incurred for any procedure which commenced before the covered person's effective date under the Plan, or any supplies furnished in connection with such procedure, except that for the purpose of this limitation, x-rays, or prophylaxis treatment shall not be deemed to commence a dental procedure.
• Charges in excess of the usual, customary, and reasonable charge. NOTE: With respect to PPO/EPO providers, the usual, customary and reasonable charge is defined as the fee allowance as outlined in the agreement between the PPO/EPO provider and the PPO/EPO.
• Complications resulting from a non-covered service.
• Congenital or developmental malformations, including congenitally missing teeth.
• Cosmetic dental procedures performed for reasons, including, but not limited to, bleaching, whitening, altering or extracting and replacing sound natural teeth to change appearance.
• Dental procedures covered under the medical benefit provisions of the Plan.
• Dental services not rendered by a dentist (D.D.S. or D.M.D.) or by a dental hygienist or x-ray technician under the supervision of a dentist.
• Duplicate or spare prosthetic devices or appliances.
• Extra oral grafts (grafting of tissue from outside the mouth to oral tissues).
• Hospital or surgical facility charges incurred for dental services.
• Myofunctional therapy.
• Night guards, athletic mouth guards, splints, or harmful habit appliances.
• Oral hygiene instructions or supplies, dietary or plaque programs, or other educational programs.
• Orthodontic treatment which commenced before the covered person became eligible for dental coverage.
• Orthodontic treatment for cases in which the desired results are unlikely to be obtained, such as those with severe periodontal problems, poor bone structure or extremely short roots.
• Orthodontic treatment for patients with severe medical disabilities which may prevent satisfactory orthodontic results.
• Orthodontic treatment plans, which, in the opinion of the Plan, are unlikely to produce professionally accepted corrections of existing malocclusion.
• Orthodontic treatment that will occasion major restorative dental work not ordinarily performed in general dentistry.
• Charges for orthodontia services furnished to covered person who becomes covered for dental benefits more than 31 days after he or she was eligible for such coverage will not be covered until the covered person has been covered under the Plan for two years.
• Charges for, or related to, Invisalign.
• Orthognathic or TMJ treatment or surgery.
• Precision attachments, semi-precision attachments or stress-breakers.
• Preparation of dental reports, itemized bills or claim forms, or charges for broken appointments, telephone calls, photocopying fees, or mailing.
• Prescription drugs (but these may be covered as a medical expense if the covered person is also enrolled in medical coverage).
• Replacement of lost or stolen appliances (i.e., dentures, bridges, orthodontic appliances, etc.).
• Services or supplies not recognized or recommended by the American Dental Association.
• Veneers.
Vision Benefits
Overview of Vision
Benefits
You can choose vision coverage for yourself or for yourself and your
Eligible Dependents. If you enroll in vision coverage, you’ll receive vision
services and supplies through the Vision Service Plan vision program, subject to
the conditions, limitations and exclusions discussed below. You can go to any
licensed optometrist or ophthalmologist (or optician for eyewear) that is part
of the Vision Service Plan vision program.
Schedule of Vision Benefits
Benefit Co-Pay Covered Amount
Limits/Exclusions
Vision Exam $10 100%
Limit of 1 every calendar year
Prescription Glasses $25
Lenses 100% Limit
of 1 every calendar year
Frames 100% (of max.) Limit
of 1 every other calendar year;
maximum of $130 retail
Contact
Lenses
$0 Up to $130 Limit of 1 every calendar
year;
in lieu of lenses/frames
Please note that the
above description is an overview of your vision benefits. In the event there is
a discrepancy between the Vision Service Plan document and this overview, the
Vision Service Plan document will be determinative.
Plan Administration
Funding &
Administration
NACOG self-funds the Plan. This means that benefits are paid from the
general assets of NACOG. The third-party administrators (see “Quick Reference
Chart” at the end of this Summary) provide administrative services (such as
claims processing) only, and don’t guarantee or insure payment of any benefits
under the Plan. BCBSAZ and HMN provide provider networks only. They do not
provide administrative or claims payment services and do not guarantee or insure
payment of benefits.
The Plan has no control over any diagnosis, treatment, care or lack thereof or other services delivered to you by a provider and disclaims liability for any loss or injury caused to you by a provider by reason of negligence, failure to provide treatment, or otherwise.
Payment Rules
Benefit PaymentsBenefit payments are
governed by the plan document, as determined by the Administrator, and may be
subject to the following controls as well as others:
• confirmation of eligibility for coverage;
• determination of medical necessity and appropriateness of the service;
• confirmation that treatment, services or supplies are a covered benefit under the Plan;
• determination that expenses are usual, customary and reasonable; and
• coordination of benefits/third party recovery (i.e., subrogation).
Recovery of Excess PaymentsIf payments are made in excess of the amount necessary to satisfy the provisions of the Plan, the Plan may recover these excess payments from any individual, insurance company or other organization to whom the excess payments were made or withhold payment on future benefits until the overpayment is recovered.
Coordination & Non-Duplication of BenefitsNACOG coordinates benefit payments with other health plans and insurance under which a person may be covered so that the total benefits paid will not exceed the charges. These provisions only apply if you (or your Eligible Dependents) are covered under another health plan or insurance in addition to NACOG’s health plan. If you are covered under another health plan or insurance (“other plan”) and our plan is considered “primary,” benefits will be paid from our plan without regard to the other plan. However, if our plan is considered “secondary,” benefits paid from our plan will be reduced by any amounts payable from the other plan.
Our plan will be considered “secondary” if the other plan does not require coordination of benefits. If the other plan requires coordination of benefits, generally, our plan will be considered “primary” for purposes of any treatment provided to an employee, but will be considered “secondary” for any treatment provided to an employee’s spouse.
For purposes of any treatment provided to your dependent children, whether our plan will be considered “primary” depends on a complicated set of rules. Generally, our plan is “primary” if your child is covered as a dependent under our plan and your spouse’s plan, you and your spouse are not divorced or separated, and your birthday occurs earlier in the year than your spouse’s. If you are divorced or separated, our plan generally will be considered “primary” if you have been ordered by the court to provide for your child’s health care expenses or if you have legal custody or your child.
If you have any questions concerning how these provisions affect your benefits, contact the Human Resources Department.
Third Party Recovery/Subrogation and Right of Recovery – The Plan has a first priority Subrogation and Reimbursement right if it provides benefits resulting from or related to an injury, occurrence, or condition for which the eligible person has a right of redress or recovery against any Third-Party.
What does first priority right of Subrogation and Reimbursement mean? It means that if the Plan pays benefits which are, in any way, compensated by a Third-Party, such as an insurance company, you agree that when a recovery is made from that Third-Party, the plan is fully reimbursed out of that recovery for the benefits the Plan previously paid. If you do not agree to the Plan’s Subrogation and Reimbursement rules, benefits will not be paid.
The rights of Subrogation and Reimbursement are incorporated into this Plan for the benefit of each participant in recognition of the fact that the value of benefits provided to each participant will be maintained and enhanced by enforcement of these rights.
Subrogation and Reimbursement - Rules for the Plan
The following rules apply to the Plan’s rights of Subrogation and
Reimbursement:
a) Subrogation and Reimbursement Rights in Return for Benefits: In return for the receipt of benefits from the Plan, the eligible person agrees that the Plan has the Subrogation and Reimbursement rights as described in this Subrogation and Reimbursement section. Further, the eligible person, or the eligible member for his his/her minor dependent will sign, if requested, a form acknowledging the Plan’s Subrogation and Reimbursement rights prior to payment, or further payment, of benefits. Benefits will not be paid if the eligible person refuses to sign the acknowledgment. Regardless of whether the eligible person refuses to sign the acknowledgment form, or if the acknowledgment form is not requested, the Plan’s Subrogation and Reimbursement rights to benefits paid are not waived or limited in any way.
b) Constructive Trust or Equitable Lien: The Plan’s Subrogation and Reimbursement rights grant the Plan an equitable lien on the proceeds of any recovery obtained by the eligible person from a Third-Party, whether by settlement, judgment, or otherwise. When a recovery is obtained, the recovered proceeds are held in trust for the Plan. The Plan then imposes a constructive trust or equitable lien on the recovered proceeds in trust, which in no way prejudices or adversely impacts the Plan’s Subrogation and Reimbursement rights. The Plan reserves the right to, among other things, pursue all available equitable actions and to offset any future benefits payable to the eligible person under the Plan.
c) Plan Paid First: Amounts recovered or recoverable by or on the eligible person’s behalf are paid to the Plan first, to the full extent of its Subrogation and Reimbursement rights, and the remaining balance, if any, to the eligible person. The Plan’s Subrogation and Reimbursement right comes first even if the eligible person is not paid for all of their claims for damages. If the Plan’s Subrogation and Reimbursement rights are not fully satisfied directly by a Third-Party, the Plan’s right to reimbursement may be enforced to the full extent of any recovery that the eligible person may have received or may be entitled to receive from the Third-Party.
d) Right to Take Action: The Plan’s right of Subrogation and Reimbursement is an equitable one and applies to all categories of benefits paid by the Plan. The Plan and any Plan member can bring an action (including in the eligible person’s name) for specific performance, injunction, or any other equitable action necessary to protect its rights in the cause of action, right of recovery, or recovery by an eligible person. The Plan will commence any action it deems appropriate against an eligible person, an attorney, or any Third-Party to protect its Subrogation and Reimbursement rights. These Subrogation and Reimbursement rights apply to claims of eligible dependents covered by the Plan regardless of whether such dependent is legally obligated for expenses of treatment.
e) Applies to all Rights of Recovery or Causes of Action: The Plan’s Subrogation and Reimbursement rights apply to any and all rights of recovery or causes of action the eligible person has or may have against any Third-Party.
f) No Assignments: The eligible person cannot assign any rights or cause of action they may have against a Third-Party to recover medical expenses without the express written consent of the Plan.
g) Full Cooperation: The eligible person will cooperate fully with the Plan and do nothing to prejudice or adversely affect the Plan’s Subrogation and Reimbursement rights. Benefits will be denied if the eligible person does not cooperate with the Plan. Repayment to the Plan is to be made within sixty (60) days of the receipt of the settlement or judgment payment from the Third-Party.
h) Notification to the Plan: The eligible person must promptly advise the Plan Administrator, in writing, of any claim being made against any person or entity to pay the member for their injuries, sickness, or death. Further, the eligible person must periodically update the Plan regarding the claim and notify the Plan of a settlement prior to reaching a compromise of their claims.
i) Third-Party: Third-Party includes, but is not limited to, all individuals, entities, federal, state or local governments, and insurers (including, but not limited to, liability, medical expense, wage loss, workers’ compensation, premises liability, no-fault, uninsured or underinsured motorist insurers), who reimburse, compensate or pay for a member’s loss, damage, injuries, or claims relating in any way to the injury, occurrence, conditions, or circumstances leading to the Plan’s payment of benefits. This right of Subrogation and Reimbursement exists regardless of whether the policy of insurance is owned by the eligible person.
j) Apportionment, Comparative Fault, Contributory Negligence, Make-Whole, and Common-Fund Doctrines Do Not Apply: The Plan’s Subrogation and Reimbursement rights include all portions of the eligible person’s claim regardless of any allocation or apportionment that purports to dispose of any portion of the claims not otherwise subject to subrogation, including, but not limited to, any apportionment for pain and suffering, wage loss, partial or total disability, or to a spouse for loss of consortium. The Plan’s Subrogation and Reimbursement rights are not affected, reduced, or eliminated by comparative fault, contributory negligence, the make-whole and/or common-fund doctrines, or any other equitable defenses.
k) Attorney’s Fees: The Plan will not be responsible for any attorneys’ fees or costs incurred by the eligible person in any legal proceeding or claim for recovery, unless prior to incurring such fees or costs, the Trustees agree in writing to pay all or some portion of attorneys’ fees or costs.
l) Course and Scope of Employment: If the Plan has paid benefits for any injury which arises out of and in the course and scope of employment, the Plan’s right of Subrogation and Reimbursement will apply to all awards or settlements received by the eligible person regardless of how the award or settlement is characterized and regardless of whether the Plan has intervened in the action. If attorneys’ fees are awarded to the eligible person’s attorney from the Plan’s recovery, the eligible person will reimburse the Plan for the attorneys’ fees.
Claims Procedure
Submitting ClaimsGenerally, if you think
you should get coverage and/or benefits under the Plan, you or your duly
authorized representative (such as a family member, doctor, or attorney) can
file a claim. You must follow this claims procedure and the appeals procedure
(discussed below) before you can bring any legal action.
When you use an In-Network provider, present your ID card to the provider. The provider will collect your co-payment and submit your claim to AEI. AEI will process your benefits at the appropriate level and send you an Explanation of Benefits showing the payment calculation and the amount you must pay. While you do not have to submit a claim for medical treatment or services rendered by an In-Network provider, you should make sure the provider submits the claim.
If you receive medical treatment or services from an Out-of-Network provider and the treatment or services is specifically covered under the Plan (see “Out-of-Network Benefits” under “Schedule of Medical Benefits” above), you must submit a claim to AEI for any covered treatment or services. For dental treatment or services, you must submit a claim to AEI. Contact AEI for a claim form. For vision services and supplies, contact Vision Service Plan (VSP).
Claims should be filed within 90 days of when the treatment or service is received. All claims must be filed within twelve (12) months following the date in which the treatment or services was first sought or, if later, first received.
The Plan, at its own expense, may require that the person whose illness, injury or disease is the basis of a claim be examined by a doctor chosen by the Plan. In case of death, the Plan may require an autopsy, unless prohibited by law.
Deciding ClaimsAEI will decide if your claim should be granted. If your claim is denied, you will receive a written or electronic notice explaining why your claim was denied. The time period for providing this notice depends on whether your claim is an urgent care, pre-service, or post-service claim (see “Types of Claims” for a description of these claims). If additional information is needed, the notice will describe the information that is needed and will explain why it is needed. The notice will explain your right to request a review of the claim denial and your right to bring a legal action if your claim continues to be denied on review. If you claim is an urgent care claim, the notice also will describe the expedited review process for urgent care claims. If an internal rule or guideline was relied upon in denying your claim, the notice will tell you this and will tell you that you have the right to request a free copy of the rule or guideline. If the denial is based on medical necessity or experimental treatment or a similar exclusion or limit, the notice will tell you this and will tell you that you have the right to request a free copy of the explanation.
Appeals Procedure
Request for ReviewIf your claim is
denied in whole or in part, you can request a review of the denial. You must
request a review within 180 days after you receive the notice of denial. Your
request for review must be in writing, but can be verbal if your claim is an
urgent care claim. The notice of denial will tell you where your request for
review must be sent.
Your Rights on ReviewYou have the right to a full and fair review of your claim. As part of the review, you also have the right to submit written comments, documents, records and other information relating to your claim. You have the right to request free copies of any records or other information relevant to your claim. If advice from medical or vocational experts was received in deciding your claim, you will be told this and will be told who these experts were. If your claim is an urgent care claim, you have the right to use the expedited review process. Under this process, your request for review can be verbal and information can be exchanged by telephone, fax, or in another similarly fast way.
Review of Denial If you request review, the Administrator (or its designee) will review your claim and the denial of your claim. All information that you submit will be considered, even if you did not provide it when your claim was first decided. The person reviewing your claim will not be the same person (or a subordinate of the person) who decided your claim in the first place. If the denial was based in whole or part on medical judgment, an appropriate health care professional will be consulted and this professional will not be the same person (or a subordinate of the person) involved in deciding your claim in the first place.
If your claim is denied on review, you will receive a written or electronic notice explaining why your claim was denied. The time period for providing this notice depends on whether your claim is an urgent care, pre-service, or post-service claim (see “Types of Claims” for a description of these claims). The notice will explain your right to receive, upon request and free of charge, copies of any documents and other information relevant to your claim. You will have the right to bring a legal action, and the notice will tell you this. If an internal rule or guideline was relied upon in denying your claim on review, the notice will tell you this and will tell you that you have the right to request a free copy of the rule or guideline. If the denial on review is based on medical necessity or experimental treatment or a similar exclusion or limit, the notice will tell you this and will tell you that you have the right to request a free copy of the explanation.
Types of Claims
Urgent Care ClaimsIf you make a claim
and the time periods that would normally apply to your claim could result in
your life, health, or ability to regain maximum function being seriously
jeopardized or your being in severe pain that cannot be managed without the care
or treatment that is the subject of the claim, then your claim will be an urgent
care claim. You will be notified of a decision on your urgent care claim within
72 hours after your claim is received, unless additional information is needed.
If additional information is needed, you will be notified within 24 hours after
your claim is received. You will then have at least 48 hours to provide the
needed information, and you will receive notice of the decision within 48 hours
of the later of when you provide the needed information or when the time period
for you to provide the needed information ends. If you request review of a claim
denial and your claim is denied on review, you will receive notice of the
decision on review within 72 hours of your request for review.
Pre-Service ClaimsA pre-service claim is a claim for benefits for which you are required to get pre-certification and which is not an urgent care claim. If your pre-service claim is denied, you will receive notice within 15 days after your claim is received, unless extra time is needed to decide your claim. If extra time is needed, the 15-day period may be extended by an additional 15 days (for a total of 30 days), and you will be notified in writing during the initial 15-day period. If the extra time is needed because you have not provided information need to decide your claim, you will have at least 45 days to provide the needed information and the time period to decide your claim will be suspended (not run) until you provide the needed information. If you request review of a claim denial and your claim is denied on review, you will receive notice within 30 days after your request for review is received.
Post-Service ClaimsA post-service claim is a claim for benefits that is not a pre-service or an urgent care claim. If your post-service claim is denied, you will receive notice within 30 days after your claim is received, unless extra time is needed to decide your claim. If extra time is needed, the 30-day period may be extended by an additional 15 days (for a total of 45 days), and you will be notified in writing during the initial 30-day period. If the extra time is needed because you have not provided information needed to decide your claim, you will have at least 45 days to provide the needed information and the time period to decide your claim will be suspended (not run) until you provide the information. If you request review of a claim denial and your claim is denied on review, you will receive notice within 60 days after your request for review is received.
HIPAA Privacy
Rights
A federal law, called the Health Insurance Portability and Accountability Act of
1996 (“HIPAA”), requires that health plans protect the confidentiality of your
private health information. A complete description of your rights under HIPAA
can be found in the Plan’s privacy notice, which was distributed to you upon
enrollment and is available from the Privacy Officer.
The Plan and the Plan Sponsor will not use or further disclose information that is protected by HIPAA (“protected health information”) except as necessary for treatment, payment, health plan operations and plan administration, or as permitted or required by law. By law, the Plan has required all of its business associates to also observe HIPAA’s privacy rules. In particular, the Plan will not, without authorization, use or disclose protected health information for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor.
Under HIPAA, you have certain rights with respect to your protected health information, including certain rights to see and copy the information, receive an accounting of certain disclosures of the information and, under certain circumstances, amend the information. You also have the right to file a complaint with the Plan or with the Secretary of the U. S. Department of Health and Human Services if you believe your rights under HIPAA have been violated.
This Plan maintains a privacy notice, which provides a complete description of your rights under HIPAA’s privacy rules. For a copy of the notice, please contact the Privacy Officer. If you have questions about the privacy of your health information or if you wish to file a complaint under HIPAA, please contact the Privacy Officer.
Medicare Part D
Notice
Please read this notice carefully and keep it where you can find it.
This notice has information about your current prescription drug coverage with
the Northern Arizona Council of Governments (NACOG) and about your options under
Medicare’s prescription drug coverage. This information can help you decide
whether or not you want to join a Medicare drug plan. If you are considering
joining, you should compare your current coverage, including which drugs are
covered at what cost, with the coverage and costs of the plans offering Medicare
prescription drug coverage in your area. Information about where you can get
help to make decisions about your prescription drug coverage is at the end of
this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. It has been determined that the prescription drug coverage offered by NACOG is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare
Drug Plan?
You can join a Medicare drug plan when you first become eligible for
Medicare and each year from November 15th through December 31st.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current
Coverage If You Decide to Join A Medicare Drug Plan?
Your current NACOG medical coverage pays for other health expenses in
addition to prescription drugs. If you and/or your dependents enroll in a
Medicare drug plan, you and/or your dependents will still be eligible to receive
medical and prescription drug benefits through NACOG. If you and/or your
dependents enroll in a Medicare drug plan, in general, the following guidelines
apply.
If you are an active employee, or the covered dependent of an active employee, you are required to obtain your outpatient prescription drug benefits through your NACOG plan first. You can then file on a secondary basis with your Medicare drug plan.
If you are a COBRA participant, or the covered dependent of a COBRA participant, you are required to obtain your outpatient prescription drugs through your Medicare drug plan first. Secondary coverage is not available through NACOG.
Important: You can only waive prescription drug coverage by waiving the entire NACOG medical/prescription plan coverage for yourself and your dependents. Remember, if you do waive your NACOG coverage, you can only re-enroll in the medical plan coverage during the next Open Enrollment Period.
When Will You Pay A Higher
Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with
NACOG and don’t join a Medicare drug plan within 63 continuous days after your
current coverage ends, you may pay a higher premium (a penalty) to join a
Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.
For More Information About
This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information. NOTE:
You’ll get this notice each year. You will also get it before the next period
you can join a Medicare drug plan, and if this coverage through NACOG changes.
You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug
Coverage…
More detailed information about Medicare plans that offer prescription drug
coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook
in the mail every year from Medicare. You may also be contacted directly by
Medicare drug plans.
For more information about Medicare prescription drug coverage:
· Visit www.medicare.gov.
· Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.
· Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
Date: January 01, 2010
Name of Entity/Sender: Northern Arizona Council of Governments
Address: 119
E. Aspen Avenue
Flagstaff, Arizona 86001-5222
Phone Number: (928) 774-1895
Plan ChangesCurrently, we intend to maintain the Plan indefinitely. However, we have reserved the right to amend or terminate the Plan at any time without prior notice to you. This means that we can decide, at any time, to eliminate, reduce, or otherwise modify a covered benefit, in which case the benefit would no longer be available to you or would be available to you only as reduced or modified. If the Plan is terminated, benefits would cease altogether.
Your ERISA RightsAs 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 participants shall be entitled to:
• Examine, without charge, at the 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) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.
• Obtain, upon written request to the 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. The administrator may make a reasonable charge for the copies.
• Receive a summary of the plan’s annual financial report. The administrator is required by law to furnish each participant with a copy of this summary annual report.
• Continue health care coverage for yourself, your spouse or 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 summary plan description and the documents governing the plan on the rules governing your COBRA continuation rights.
• Reduction or elimination of exclusionary periods of coverage for pre-existing conditions under your group health plan, if you have credible 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 issuer, 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 pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.
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 discriminate against you to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
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 frames.
Under ERISA, there are steps you can take to enforce your rights. For instance, if you request a copy of the plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent for reasons beyond the control of the administrator. If you have a claim for welfare benefits that is denied, in whole or in part, you may request review of the denial. If your claim is denied upon review or if your claim is ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in a federal court (after your claim is denied on review or if your claim is ignored). 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 will pay the 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.
If you have any questions about the plan, you should contact the administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits 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 Pension and Welfare Benefit Administration.
Plan Name NACOG Employee Benefit Plan
Group
Numbers
Medical – NAC 534
Dental – AEI 5345
Vision – VSP 12 252326
Plan Number 501
Type of Plan Medical, Dental and Vision
Plan Year January 1 through December 31
Plan
Sponsor/Administrator
Northern Arizona Council of Governments
(Enrollment, Changes, Contributions)
119 E. Aspen Avenue
Flagstaff, Arizona 86001-5222
(928) 774-1894 x1181
ksweet@nacog.org
Employer ID Number: 86-0262631
Privacy
Officer
NACOG Director of Administration
119 East Aspen
Flagstaff, Arizona 86001-5222
(928) 774-1895
Claims
Administrator
Administrative Enterprises, Inc. (AEI)
(Claims & Benefits Information)
5810 West Beverly Avenue
Glendale, Arizona 85306-1800
(602) 789-1170 (800) 762-2234
www.aeitpa.com
Eligibility / Description of
Benefits AEI FAX
(602) 789-9369
www.aeitpa.com
Vision
Administration
Vision Service Plan (VSP)
3333 Quality Drive
Rancho Cordova, CA 95670-9757
(800) 877-7195
Medical Review
American Health Group (AHG)
(Case Management & Pre-certification)
2152 S. Vineyard Avenue, Suite 103
Mesa, Arizona 85210-6881
(602) 265-3800 (800) 847-7605
Preferred/Exclusive Provider Organizations
Blue Cross Blue Shield of Arizona
(Names of Physicians & Hospitals in PPO/EPO Network)
P.O. Box 13466
Phoenix, Arizona 85002-3466
(800) 232-2345
www.azblue.com
(BlueCross© BlueShield© of Arizona, an independent licensee of the BlueCross© BlueShield© Association, does not provide administrative or claims services for the NACOG Employee Benefit Plan. The Plan has assumed all liability for claim payments. No BlueCross© BlueShield© provider network benefits are available outside of Arizona.)
(In addition, for members
residing Health Management Network
of Utah
in the Fredonia, Arizona area)
1600 West Broadway, #385
Tempe, Arizona 85282-1137
(800) 448-3585
Prescription Drug
Program Walgreens Health
Initiatives
(800) 207-2568
www.mywhi.com
Sources of Contributions Employee contributions and the general assets of the Employer
Agent for Service of
Process Mangum, Wall, Stoops
& Warden
100 North Elden, P.O. Box 10
Flagstaff, AZ 86002-0010
(928) 779-6951
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