2016 Preferred Provider Organization (PPO)

Transcription

1 2016 Preferred Provider Organization (PPO) Benefits at a glance for Chrysler UAW Trust members Group Number: 71434

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3 Contents Preferred Provider Organization... 2 Cost sharing summary and benefits at a glance... 4 Understanding important terms... 5 Explanation of benefits Claims questions and appeals Contact information...back cover 1

4 Preferred Provider Organization You have many options when it comes to choosing health care. Thank you for choosing the Blues. ms/definitions Hospital care Call/nursing telephone support Hospital and other services Alternatives to hospital care Plan benefits Ready to join Maternity care We offer: Preferred Provider Organization (PPO) health plan (for members under and over 65 years old) Who can join Medicare Advantage health plan (for members enrolled in Medicare who are at least 65 or deemed eligible for Medicare) and other services es to hospital care nal medicare Plan benefits Ready to join Maternity care Other services Mental health and substance abuse treatment Questions Leaving the hospital DME Organ transp Blue Care Network and Blue Care Network Advantage health plans (in Michigan only) Who can join Member Physicians/Providers As a member of the UAW Retiree Medical Benefits Trust, you can choose one of several Blue plans that meet your needs and those of your family. Each plan offers you the same great benefits that come with being a Blue Cross Blue Shield of Michigan member. he hospital Questions DME Preventive care Prescription drugs Deductible, and dollar maximums Reasons to join Physicians/Providers Call/nursing telephone support Eye car Organ transplant Member Missouri Customer service There is always extra value when you choose Blue. With every Blue card, you receive additional support. Some of the programs we offer members include: Important terms/definitions com/online/live n drugs MyBlue Medicare Magazine Deductible, and dollar maximums Important terms/definitions Hospital care Physician office services Reasons to join Hospital care Outpatient diagnostic services Hospital and other services Alternatives to hospital care Surgical services Call/nursing telephone support Beyond original medicare Tobacco cessation Surgical services heart failure or COPD SilverSneakers Facing a complex medical condition hearing Hospital and other services Alternatives to hospital care care PlanEye benefits Ready to join Other services Emergency hearing services Shot Who can join Pneumonia Customer service Mental health and substance abuse Leaving the hospital treatment Coping with heart failure or COPD Facing a complex medical condition Questions DME Where am i covered Who can join Research monitors Case Management solutions that assist with medical issues, give you access to experts who can coordinate treatments, and provide guidance and support. Questions Other services Mental health and substance abuse Leaving the hospital DME treatment You can call for direction. Shot Beyond original medicare Ready to join Our tobacco cessation program that teaches you self-management and coping skills for smoking intervention and cessation. You can call to get started. Missouri s diagnostic services Plan benefits Where am i covered Pneumonia Preventive care Member Physicians/Providers Prescription drugs Research monitors Deductible, and dollar maximums Reasons to join Physicians/Providers Online health resources at bcbsm.com that include more than 90,000 medically reviewed resources in a number of formats, such as: Missouri SilverSneakers Internet/bcbsm.com/online/live coaching Internet/bcbsm.com/online/live Everyday savings coaching Preventive care Prescription drugs Deductible, and dollar libraries, encyclopedias and directories videos, calculators, podcasts, and animations decision making guides and interactive quizzes MyBlue Medicare Magazine MyBlue Medicare Magazine Tobacco cessation Physician office services Physician office services Emergency services Outpatient diagnostic services Surgical servicesmaximums Outpatient diagnostic services Coping with heart failure or COPD Surgical services Facing a complex medical condition Customer ser Reasons to join hearing Shot Pneumonia Missouri hearing Where am i covered Research monitors Shot Pneum Healthy Blue XtrasSM and Blue 365 programs offering discounts and exclusive savings on products, nutrition, travel, recreation, and gym memberships. 2 Everyday savings Tobacco cessation Emergency services Coping with heart failure or COPD Facing a complex medical condition Where am i covered Research monitors

5 With the Preferred Provider Organization product (referred to as PPO), you have access to the largest network of doctors, hospitals, and other health care providers from which to choose. Our large network gives your family access to thousands of doctors and hospitals. More than likely, any doctor or hospital you choose will be in the network. Along with our expansive network, you will usually pay less when you use an in-network provider. Deductibles, co-insurance, copayments, and overall out of pocket expenses are less when you choose to use an in-network provider. If you go outside of the vast network of providers however, you will have to pay more for services. It s easy to check to see if your provider is in the network by calling customer service at or going to bcbsm.com and searching under Find A Doctor. If you ever have any questions about your coverage bills you may have received your explanation of benefits contact customer service at You can always find that number on the back of your card. Customer service representatives will be happy to answer any questions you may have. Thank you for being a member of Blue Cross Blue Shield of Michigan. Thank you for choosing the Preferred Provider Organization product. 3

6 2016 Benefits at a glance with cost sharing summary Monthly contribution and out-of-pocket expenses In network Monthly contribution The monthly amount you must pay in order to have coverage for yourself and your dependents Individual: $17 Family: $34 Deductible per calendar year Individual: $425 Family: $720 Individual: $1,000 Family: $1,700 Coinsurance 10% 30% Out of pocket maximum per calendar year Combination of deductible and Individual: $1,200 Family: $2,220 Individual: $3,000 Family: $5,550 4

7 Understanding important terms Insurance pays 100% Out-of-pocket maximum met $$$ Coinsurance (you and insurance share cost) Deductible met $$ Deductible (you pay) Deductible The amount you must pay toward covered medical services within a calendar year before the Plan begins to pay. This does not apply to services that require a copay. Coinsurance The percentage you pay for covered services after you have met your deductible. Out-of pocket maximum The total amount you will pay in a calendar year. It is a combination of the deductible and. Once paid, all covered services are paid at 100% for the rest of the calendar year. Copayment (copay) A fixed amount you pay to receive a medical service, usually at the time the service is performed (office visits, emergency room, urgent care). Note that the copayment does not go toward paying the deductible, or out-of-pocket maximum. Copays are separate and continue even after your out-of-pocket maximums are met. In-network providers Providers (i.e., hospitals and doctors, etc.) that sign a contract agreeing to accept the allowed amount for a service as payment in full so that members will not be billed for the balance. Out-of-network providers Providers (i.e., hospital and doctors, etc.) that have not signed a contract with the Blues to accept the approved amount and may bill for balances. Out-of-network providers may result in higher out-of-pocket costs. 5

8 2016 Benefits at a glance Preventive services In network Pap Smear Screenings one per calendar year Covered 100% Mammography Screening Routine and high-risk mammogram screening in accordance with guidelines established by the American Cancer Society one routine exam per calendar year beginning at age 40. Under age 40, one per calendar year, if high-risk factors are present Prostate Specific Antigen (PSA) Screening Screening test for asymptomatic males age 40 and older when performed in accordance with guidelines established by the American Cancer Society one per calendar year Early Detection Screening Tests Early detection screening for colon and rectal cancers when performed in accordance with guidelines established by the American Cancer Society. Barium Enema X-ray one every 5 years age 50 and over (or at any age if risk factors are present); or Colonoscopy one every 10 years age 50 and over (or at any age if risk factors are present); or Sigmoidoscopy one every five years age 50 and over (or at any age if risk factors are present) Fecal Occult Blood Test one per calendar year beginning at age 50 Total serum cholesterol with low density lipoprotein (LDL) one test every 5 years beginning at age 20 Hepatitis C (HCV) Screening For enrollees who are at risk or when signs or symptoms are present which may indicate a Hepatitis C infection Covered 100% Covered 100% Covered 100% Covered 100% Well Baby Six visits up to age 2 Covered 100% Immunizations age and frequency limitations for selected medically recognized immunizations at doctor s office, retail health clinic, and certain immunizations at Covered 100% a pharmacy. Bone Marrow Screening 6

9 Mental health and substance abuse treatment Leaving the hospital Questions DME Organ transplant Physicians/Providers Member Physician office services Preventive care Prescription drugs Deductible, and dollar maximums Office Visits not subject to deductibles or out-of-pocket maximums In network Covered 50% Office Consultation & Outpatient Consultation not Covered 50% subject to deductibles or out-of-pocket maximums Physician office services Outpatient diagnostic services Surgical services hearing Retail Health Clinics Covered $50 copayment Emergency medical care Emergency services Coping with heart failure or COPD Facing a complex medical condition Reasons to join Where am i covered Hospital Emergency Room Services rendered in the emergency room of a hospital for initial examination and treatment of condition resulting from accidental injury or qualifying medical emergency are covered. Medical emergencies will be considered to exist only if medical treatment is secured within 72 hours after the onset of condition. In network Covered $125 copayment waived if admitted Covered $125 copayment waived if admitted Physician Qualified Medical Emergency & First Aid Services Initial examination and treatment of a qualifying condition resulting from accidental injury or qualifying medical Covered 100% Covered 100% emergency. Medical emergencies will be considered to exist only if medical treatment is secured within 72 hours after the onset of condition. Urgent Care Centers Covered $50 copayment Ground Ambulance medically necessary transport Air/Water Ambulance Covers one-way transport from the scene of an emergency incident to the nearest available facility qualified to treat the patient, or transporting a patient one-way or round-trip from home to the nearest available facility qualified to treat the patient, or transporting a patient one-way or roundtrip from home to the nearest available facility qualified to treat the patient. Medical emergency/accidental injury patients are provided one-way transportation from home to the facility. Home bound patients are provided round trip transportation from home to the facility and back when medically necessary and when other means of transportation could not be used without endangering the patient s health. Research monitors Covered 100% up to the allowed amount Covered 100% up to the allowed amount Medical Emergency/Accidental Injury: Follow-Up Care Missouri Shot Pneumonia Customer service Eye care 7

10 2016 Benefits at a glance Diagnostic services Outpatient Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA) Use of MRI for diagnostic examination for all body parts when ordered by a physician and performed on approved equipment. Must be performed at approved facilities. Preauthorization may be required. Other Outpatient Diagnostic Tests, X-rays, Laboratory & Pathology, PET, CAT Scans and Nuclear Medicine Preauthorization may be required. Radiation Therapy for the diagnosis of condition, disease or injury. Preauthorization may be required. In network ce Maternity care Pre-Natal and Post-Natal Care Delivery and Nursery Care Organ transplant Maternity services provided by a physician Abortions must be medically necessary. For medically induced abortion by oral ingestion of medication when medically necessary Certified Nurse Midwife Eye care For a given uncomplicated pregnancy, reimbursement for such care would be to the physician or certified nurse midwife, but not both. Obstetrical services by certified nurse midwives are limited to basic antepartum care, normal vaginal deliveries, and postpartum care. Certified nurse midwives are reimbursed only for deliveries occurring in the inpatient setting or in a birthing center that is hospital affiliated, state licensed and accredited and approved by the carrier. The certified nurse midwife must be legally qualified and registered, certified nurse and/or licensed, as applicable, to perform these health care services. In network 8

11 Hospital care Semi-Private Room, General Nursing Services, Meals and Special Diets (Predetermination required for non-medicare members) Inpatient Medical Care Chemotherapy Coverage is provided for treatment of malignant disease and Hodgkins disease, except when the treatment is considered experimental or investigational. In network Covered for emergency admissions only subject Maximum 365 days for each continuous period of hospital confinement or for successive periods of confinement separated by less than 60 days. ort abuse Hospital and other services Alternatives to hospital care Alternatives to hospital care Ambulatory Surgical Centers (Facility must satisfy Program requirements and be an approved facility) Who can join Leaving the hospital Plan benefits Skilled Nursing Facility (Must be an approved BCBS Skilled Nursing Physicians/Providers Facility) Prescription drugs Questions Deductible, and dollar maximums Hospice Care (Provider approval required) Home Health Care (Facility approval required) Ready to join DME Outpatient diagnostic services Surgical services hearing Coping with heart failure or COPD Facing a complex medical condition Reasons to join Where am i covered Missouri Shot Research monitors Pneumonia Member Customer service In network Maternity care Organ transplant Limited to 100 days per benefit period. Renewable after 60 days of continuous non-confinement. Eye care Limited to 2 days of hospice care for each remaining inpatient hospital day. Lifetime maximum of 210 days. Limited to 3 home health care visits for each remaining day of the inpatient hospital benefit period as long as the patient is medically eligible. Each visit by member of the home health care team, and each home health aide visit is considered the equivalent of 1 home visit. 9

12 2016 Benefits at a glance aternity care Outpatient surgical services Surgery includes materials, supplies, preoperative and postoperative care, and suture removal Voluntary Sterilization excludes reversal sterilization In network Organ transplant Human organ transplants Specified Organ Transplants Preauthorization by Human Organ Transplant Program is required. All members must be enrolled in case management. Must be performed in a Blue Call/nursing Distinction telephone support Center. Hospital and other services Plan benefits Ready to join Eye care Alternatives to hospital care In network Maternity care Mental health and substance abuse treatment Mental health care and substance abuse treatment Leaving the hospital Questions Preventive care Prescription drugs Deductible, and dollar maximums Services must be preauthorized by ValueOptions. For preauthorization, call (not mandatory for Medicare enrollees) Physician office services Outpatient diagnostic services Surgical services hearing Emergency services Coping with heart failure or COPD Facing a complex medical condition DME Reasons to join Where am i covered Missouri Shot In network Inpatient: Inpatient: Organ transplant Up to 45 days treatment unless Member each for psychiatric medical emergency and substance abuse admission. covered 100% up to the allowed amount. Who can join Physicians/Providers Research monitors Eye care Outpatient: Customer service Mental Health: Up to 35 visits covered per benefit period Visits 1-20: 100% up Pneumonia to the allowed amount, Visits 21-35: 75% up to the allowed amount. Substance Abuse: Up to 35 visits per benefit period covered at 100% up to the allowed amount. Outpatient: Mental Health: Up to 35 visits covered per benefit period Visits 1-20: 100% up to the allowed amount, Visits 21-35: up to 75% of the allowed amount. Substance Abuse: Up to 35 visits per benefit period covered at 100% up to the allowed amount. 10

13 In network Allergy Testing Allergy Therapy/Serum Other services Chiropractic Care Emergency first aid and diagnostic X-ray of the spine only. Excludes adjustment manipulation and initial office visit Outpatient Physical, Speech and Occupational Therapy (medical necessity required) Limited to 60 combined visits per calendar year, per condition. Services are covered when performed in the outpatient department of the hospital or approved freestanding facility. Therapy is also covered when provided by an in-network independent physical therapist, an independent occupational therapist, or speech and language pathologist. Durable Medical Equipment* Covered 100% Prosthetic and Orthotic Appliances Hair Pieces and Wigs Wigs and appropriate related supplies (stand and tape) are covered for any age for an individual who is suffering hair loss from the effects of chemotherapy, radiation therapy or other treatments for cancer. For the initial purchase of the wig and related supplies, the maximum benefit is $250. Thereafter, the maximum annual benefit is $125. Prosthetic and Orthotic: Jaw Motion Rehabilitation (Jaw motion rehabilitation system and related items) Diabetes Education Covers comprehensive American Diabetes Associationapproved education classes for newly-diagnosed or uncontrolled diabetics. Cardiac Rehabilitation Only Phases I and II are covered Must begin within 3 months of a cardiac event and be completed within 6 months. Covered 100% Covered 100% Up to 36 sessions (3 sessions per week for 12 weeks) covered at 100% up to the allowed amount Prosthetic & Orthotic appliances are not covered with the exception of wigs *Durable Medical Equipment Subject when processed as part of inpatient services or office services. 11

14 2016 Benefits at a glance aternity care aring Hearing care must be a participating provider Audiometric exam once every 36 months Hearing aid evaluation once every 36 months Ordering and fitting the hearing aid (one monaural) standard or digital every 36 months Binaural hearing aids for children 19 and under once every 36 months Organ transplant Hearing aid conformity test once every 36 months In network 100% up to the allowed amount 100% up to the allowed amount 100% up to the standard hearing aid allowance 100% up to the allowed amount. 100% up to the allowed amount Vision care medical coverage Eye care In network Routine exam Under the medical coverage, one routine vision exam covered with a $25 copayment, once every 24 months. Under the medical coverage, one routine vision exam covered with a $25 copayment, once every 24 months. Routine exams, frames, lenses and additional services -- Contact Davis Vision at

15 use Questions Leaving the hospital DME Organ transplant Member Prescription drugs Physicians/Providers Coverage administered by Express Scripts Prescription drugs Deductible, and dollar maximums Reasons to join Retail (One-Month Supply) Mail Order Outpatient diagnostic services Surgical services (90-Day Supply) Tier 1: Generic $12 Tier 2: Preferred Brand $40 Missouri Customer service Tier 3: Non-preferred Brand $100 Tier 1: Generic $24 Tier 2: Preferred Brand $80 hearing Tier 3: Non-preferred Brand $200 Shot Coping with heart failure or COPD Facing a complex medical condition Eye care Where am i covered Prescription Drug Categories Pneumonia Research monitors Tier 1: Generic Medications (Equivalents or Alternatives) Important terms/definitions Tier (Single Source, Sensitive Drug Classes) Hospital2: care Brand Medications Call/nursing telephone support Hospital and other services Preferred Plan benefitsbrand, andready to join Alternatives to hospital care Tier 3: Brand Medications (Multi-Source or Non-Preferred Brand) Who can join Beyond original medicare Other services Mental health and substance abuse treatment Leaving the hospital Questions DME M Physicians/Providers SilverSneakers Preventive care Prescription drugs Deductible, and dollar maximums Reasons to join Missouri Internet/bcbsm.com/online/live coaching MyBlue Medicare Magazine Physician office services Outpatient diagnostic services Surgical services hearing Shot Everyday savings Tobacco cessation Emergency services Coping with heart failure or COPD Facing a complex medical condition Where am i covered Pneumonia Research monitors 13

16 EOB stands for Explanation of Benefits As a member of the Traditional Care Network plan, once you have services performed, you will receive an Explanation of Benefits, or EOB. The EOB will show you: What services you had and what the provider billed What your Plan paid and any Blue Cross discounts that were applied The amount you may owe through deductibles, or copayments Any non-covered services that were not payable through your benefit plan Reviewing your EOB statements is a good way to keep track of your medical care. EOB Statement Details 1 2 Identifies who this EOB statement is for. Summarizes claims by doctor, hospital, or other health care provider as follows: 5 A The amount submitted to Blue Cross on the claim. 1 B What you saved by being a Blue Cross member. C D E 3 4 What Blue Cross paid. Amounts any other insurance(s) paid. What you pay. You may have already paid or may still owe this amount. You should never be asked to pay more than this amount. Shows the balances to date for deductibles and out-ofpocket maximums for your current benefit period. Important information about your coverage, tips to lower health care costs, and ways to improve overall health A B C D E 5 14 Customer Service information if you have questions about something on your statement. The statement shown is general and for illustrative purposes only. Your actual statement may look slightly different depending on your benefit plan.

17 6 F G Detailed information about each claim we processed. The sum of all claims in this section for the same provider should match the numbers in the Claim Summary section. Information your provider puts on the claim to identify the medical service you received. The unique number Blue Cross assigns to a claim. You can reference this number if you need to call us about this claim. 6 F G Page 2 of your statement shows your appeal rights and what you can do if you disagree with any of the benefit decisions made for a claim. You can also find definitions for terms used on the statement. Online EOBs Log in at bcbsm.com if you want to view recent claims, deductibles, balances, and other information. It s easy: 1. Go to bcbsm.com and follow steps to create a login account. 2. After logging in, select Claims in the blue bar near the top. 3. Click on Explanation of Benefits statements. Help us prevent fraud Checking to make sure you actually received services as shown on the EOB helps us prevent error and fraud. Call your customer service number , if you have questions about a claim or EOB. 15

18 Claim questions and appeals 1 To confirm you are paying the right amount, compare the EOB and the provider bill side-by-side. Match the service dates and the amounts. If they match, pay the provider that amount and file the EOB for your records. 16

19 After your claims are submitted to BCBS by your providers, you will receive an Explanation of Benefits. In addition, you will most likely receive a billing statement from your provider, showing any outstanding balances you may owe. 2 If the amounts do not match, or if you have questions, call customer service at , as shown on the back of your BCBS identification card. A BCBS representative will be happy to review the EOB statement and answer your questions. 3 If you are not satisfied with the response or outcome from customer service, you may file an appeal with BCBS by completing an Auto/Inquiry Appeal form. The BCBS customer service representative can help you obtain the form. 4 Once you receive the form, make sure to attach an explanation of your concern and copies of the statements in question. Check the Appeal Box on the form and mail to: 5 If the issue remains unresolved, you may file an appeal with the UAW Trust. Please see your Summary Plan for details. Auto National Appeal Unit 600 Lafayette East Mail Code #2004 Detroit, Michigan

20 Contact information Blue Cross Blue Shield of Michigan Hospital, Surgical/Medical Services For questions on benefits, claims or how to locate providers, 8 a. m. - 8 p.m. Eastern time, Monday Friday Mailing Address (for claim inquiries): UAW Auto Retiree Service Center P.O. Box Detroit, Michigan ValueOptions Help Line Precertification Mental Health and Substance Abuse (required for non-medicare members only) Blue Card Access National Provider Network Information on participating network providers at home and while traveling Case Management Coordination of health care Retiree Health Care Connect The UAW Trust eligibility and call center Eligibility, membership, address changes, and ID card requests Tobacco Cessation Express Scripts (formerly Medco Health) Mail Order and Retail (Drug Stores) Prescription drug questions Delta Dental Davis Vision Medicare medicare.gov Veterans Health Administration va.gov/health UAW Retiree Medical Benefits Trust uawtrust.org Blue Cross Blue Shield of Michigan is proudly represented by the UAW R PPO