MEDICAL BENEFITS. Medical PPO Network: Beechstreet. (800)

Transcription

1 MEDICAL BENEFITS Fund Name: Cement Masons & Plasterers Health & Welfare Trust Fund ID: V100 SPD Version: July 2014 Who is Covered: Actives, Retirees & Dependents Tax ID: Revised: 8/24/16 SA Trust Fund Contact Information: To access eligibility, claims status and summary of benefits for medical, dental and/or vision as well as to contact the Trust Fund Office for general questions, please visit our Provider Portal or our WebSupport: Utilization and Case Management: Innovative Care Management (ICM) (800) PO Box 875 Gladstone, OR Medical PPO Network: Beechstreet (800) Correspondence (no claims): Commercentre Drive Lake Forest, CA Hospital PPO Network: Health Service Coalition (702) Prescription Benefit Management: Envision Rx (800) Alpha Prefix: CEM PCN: ROIRX Group: CMPHWT Mail claims to (including Health Service Coalition, Behavioral Health Care Options, Dialysis Preservation claims): Cement Mason & Plasterers Health & Welfare Trust PO Box 1618 San Ramon, CA EDI Payor ID: Dialysis Related Services: Dialysis Preservation Program PPO Mental Health & Substance Abuse (MAP): Behavioral Health Care Options (702) or (800) Our system is ICD-10 compliant for claims after 10/1/15.

2 Coordination with Medicare Prior authorization Timely Filing Limit The eligible expenses that are not paid because of copayments, deductibles, or other coverage restrictions by Medicare will be considered for payment by the Plan. If a medical procedure is not covered by Medicare but is covered by the Plan, then the Plan will cover that service for Medicare participants in the same manner as for active participants. Hospitalization; Inpatient and outpatient surgeries; diagnostic tests/medical procedures; Durable medical equipment or ancillary testing in excess of $5,000; Home Health Care, including Home IV/Infusion; Speech therapy for developmentally delayed; Skilled Nursing Facility or Rehabilitation facility; MRI/ CT/ PET/ CAT scans and nerve conduction testing and electrocardiograms; Surgical back injections or back surgeries and Infusion Therapy. If no prior authorization obtained, benefits are reduced to 50%. All claims must be submitted within 24 months from the date of service. Health Service Coalition filing limits apply for their providers. Plan has authority to MANDATE case management. If member/patient or his treating providers refuse or fail to participate in & fully cooperate with LCM when required by the Plan, then the Plan has the authority to reduce all Plan benefits by 75%. All services are subject to deductible & allowable expenses, unless otherwise noted. Benefit In-Network Out-of-Network Out-of-Area Comments Office Visit Copayment $15 $15 $15 No copay if Medicare is primary Deductible $150 Individual/ $300 family $600 Individual/ $1,200 Family Common Accident Deductibles $150 $600 $150 Effective 1/1/16: No annual out of pocket maximum for nonemergency services. $600 Individual/ $1,200 Family 4th Quarter Carry-over applies Out-of-Pocket Maximum $3,500 Individual or $10,500 Family For Emergency Services ONLY: $6,600 Individual or $13,200 Family No PPO available $3,500 Individual $10,500 Family The Out of Pocket maximum will now accumulate deductibles, copayments, coinsurance and prescription drug expenses. Date of service 12/31/15 and Prior: For Non-Emergency Services: $6,600

3 Effective January 1, 2016 St. Rose / Dignity Health facilities will be contracted with Health Services Coalition (HSC). Services will be payable at the PPO benefit level. Effective January 1, 2014, the following facilities (St. Rose/Dignity) will no longer be In-Network: -St. Rose Siena Hospital -St. Rose San Martin Hospital -St. Rose De Lima Hospital -Durango Surgery Center Parkway Surgery Center Emergency Services only will be paid at 35% In-Network of Billed Charges as usual & customary. Non-Emergency Services will NOT be covered. EFFECTIVE JANUARY 1, 2016 The above restriction will be removed as Dignity Health Hospitals will be considered a PPO provider. Claims with a date of service prior to 1/1/16 will still be considered out of network with the above restriction in force. NOTE: If out-of-network radiology, pathology, anesthesiology, ER physician services are rendered while in an in-network facility, the services will be paid as In-Network, (90%/10%). Out-of-Network benefits are never paid at 100%. Annual Max No Annual Maximum Dependents Covered to age 26 COB Provisions Timely Filing Limit Plan follows birthday rule All claims must be submitted within 24 months from date of service. Health Service Coalition contract filing limits apply for their providers. Benefits Beechstreet Out-of-Network Out-of-Area Comments Abortions (Elective) Accident Work Related Not Covered First $300 at 100% - No deductible if within 36 hours of an accident and first 3 months of treatment. There is a common accident deductible (only 1 individual deductible applies if more than one family member is in the same accident.) (Dental treatment, chiropractic and acupuncture are excluded from this benefit.) Not Covered Motor Vehicle Accidents 90% 75% 80% Other 90% 75% 80% Acupuncture 90% 80% 80% $300 per year Allergy Testing/Injections 90% 75% 80% Requires Prior Authorization Ambulance For Emergency Room treatment immediately following an accident or for an In-patient Admission. Benefit also pays to/from hospital provided patient is being admitted/discharged as a bed patient.

4 Air 90% 80% 80% Ground 90% 80% 80% Birth Control See Routine/Preventive Care Section under Contraceptives Blood 90% 75% 80% Chiropractic 10 visits per calendar year Exam & Modalities 90% 75% 80% X-rays 90% 75% 80% Consultations 90% 75% 80% Court Ordered Treatments Dental Surgery Diabetic Supplies & Insulin Not covered Not covered except for treatment of tumors or general anesthesia for dependent children for dental procedures when medically necessary. All diabetic supplies, which include lancets, test strips, syringes (if filled with insulin), and needles will be covered free of charge to the patient if obtained from a network pharmacy through the Prescription Plan. Diagnostic Labs, Outpatient 90% 75% 80% Diagnostic X-rays, Out of Area 90% 75% 75% Diagnostic X-rays, Outpatient 90% 65% 65% Premarital examinations or x-ray treatments are not covered. Some outpatient services require pre-authorization before benefits will be covered (Cardiac monitoring, Echocardiography, CT/CTA, MRI/MRA, Myocardial perfusion Imaging [Thalium], PET scans) All dialysis-related claims will be processed thru the Plan's Dialysis Preservation Program. Dialysis Services (Outpatient) Covered persons who are eligible for secondary coverage, such as Medicare Part B, are encouraged to obtain such coverage. The Plan will not pay for any costs which would have been payable by such secondary coverage. Dialysis services are payable per UCR, as determined by the Dialysis Preservation program, subject to deductibles/coinsurance. Any provider who accepts the payment from the Plan, will be deemed to consent & agree that such payment shall be for the full amount due for the provision of services & supplies AND shall not balance bill a covered person for any amount billed but not paid by the Plan.

5 DME rental or purchase over $500 & DME replacements requires Prior Authorization with ICM call Durable Medical Equipment 90% 75% 80% See Routine/Preventive Care section for Breast Pump (DME) benefits. Please submit DME purchase price, prescription, and first date of rental with the initial claim. $500 Emergency Room Co-pay for Non-Emergency visits. Emergencies are defined as immediate medical treatment for life-threatening, disabling or disfiguring medical conditions or accidental injuries. Emergency Care Emergency Services only for St. Rose/Dignity facilities will be paid at 35% of billed charges as In-Network as the usual & customary. Non-Emergency services at Dignity facilities will not be covered. EFFECTIVE JANUARY 1, 2016 The above restriction will be removed as Dignity Health Hospitals will be considered a PPO provider. Claims with a date of service prior to 1/1/16 will still be considered out of network with the above restriction in force. ER: Illness 90% 90% 90% The Annual Out of Pocket Maximum for Emergency Services performed by Non-PPO Providers will not Physician 90% 90% 90% exceed the annual limit permitted by Health Care Reform, which is $3,500 ind./$10,500 fam. For Non- Emergency claims, the Annual Out of Pocket Maximum is $6,600 ind./$13,200 fam. Urgent Care Facility 90% after $15 copay 90% after $15 copay 90% after $15 copay Extended Care Facility Foot Care (Routine) Office visit See Benefits for Skilled Nursing Facility Effective 1/1/16: There is no annual out-of-pocket maximum for non- Emergency services provided by Non-PPO Providers. Fund does cover medically necessary non-surgical treatment of the feet relating to chronic conditions, such as diabetes, peripheral neuropathy & arteriosclerosis. Non-surgical treatment for hammertoe, plantar fascilitis, bursitis & other foot-related conditions are not covered. 100% after 75% 80% $15 Co-pay Surgery 90% 75% 80% Testing 90% 75% 80% See Diagnostic, X-rays, and Labs benefit Orthotics/Diabetic Shoes 90% 75% 80% Prior to 5/1/14: $500 Maximum every two years to the extent such equipment is not considered Essential Health Benefits Effective 5/1/14: maximum of one pair every two (2) years.

6 Genetic Testing Hearing Benefit (No Deductible) Not covered except as provided under the Routine/Preventive Care section. Exam is not payable if no aid is purchased. Prior to 5/1/14: $500 Maximum per ear, per 3 year period Effective 5/1/14: Maximum of one (1) device per ear every five (5) years. Aid 80% 80% 80% Exam 80% 80% 80% Testing 80% 80% 80% Home Health Care 90% 80% 80% Home IV Infusions 90% 80% 80% Requires Prior Authorization Hospice 90% 90% 90% Requires Prior Authorization Bereavement Counseling 90% 90% 90% Hospitalization Respite Care Coverage for respite care is limited each time to stays of no more than 5 days in a row. Respite Care is short term inpatient stays that may be necessary for the patient in order to give temporary relief to a caregiver who regularly assists with home care. Dignity Health Elective Services. The Plan does not provide coverage for any elective services provided at a Dignity Health Hospital or Surgical Center. EFFECTIVE JANUARY 1, 2016 The above restriction will be removed as Dignity Health Hospitals will be considered a PPO provider. Claims with a date of service prior to 1/1/16 will still be considered out of network with the above restriction in force. Room & Board 90% 75% 80% Semi-private room rate Ancillary 90% 75% 80% Precert Pre-authorization is required through ICM ICU/CCU 90% 75% 80% Up to 2 1/2 time Semi-private rate Physician 90% 75% 80% Hospitalist Service 90% 75% 80% Participation in the Hospitalist Program is mandatory. Hospitalists are licensed primary-care physicians who practice exclusively in hospitals. Specialists such as OB/GYN, Pediatric, Oncology or other specialties are not part of the Hospitalist Program. Advantage to patients is they will have no out-of-pocket expenses (i.e. deductibles, co-insurance, or co-pays). Patients who refuse care under the Hospitalist Program will be responsible for 100% of the Billed Charges by non- Hospitalist physicians.

7 Infertility Fertility testing & treatment are not covered by the Plan. Injections 90% 75% 80% IV Infusions 90% 75% 80% Maternity See Routine/Preventive Care section for specific benefits covered at 100%. Pre Natal Visits Effective 7/1/15 Post Natal Visits 90% 75% 80% $15 co-pay Delivery 90% 75% 80% Newborn Care 90% 75% 80% Dependent Daughter Mental Nervous & Substance Abuse (Acute Hospital) Inpatient Residential In-patient, Group Homes, Half-way homes & Intensive Day Treatment Outpatient Screening and counseling for interpersonal and domestic violence Psychological Testing Social Worker Counseling Credentials Not covered except for benefits specifically provided under Routine/Preventive Care Section. Newborn of dependent daughter not covered. 90% If authorized by MAP 90% If authorized by MAP 100% If authorized by MAP 100% If authorized by MAP Must be approved thru (MAP) Behavioral Health Care Options for Network Benefit. 75% If authorized by MAP 75% If authorized by MAP 75% If authorized by MAP 75% If authorized by MAP 50% If not authorized by MAP 50% If not authorized by MAP 50% If not authorized by MAP 50% If not authorized by MAP Pre-authorization is required. Deductible waived for MAP approved intensive outpatient treatment. Deductible waived for routine outpatient therapy and outpatient medication management. Referral by a Physician for Clinical Social Worker or Licensed Marriage Counselor, or Family Therapist Child Counselor. Physician, Psychologist or Outpatient Psychiatric Clinic Obesity Not covered except as provided under the Routine/Preventive Care section. Office Visits 90% 75% 80% $15 co-pay Minute Clinics 90% 75% 80% $15 co-pay

8 Pain Management 90% 75% 80% Penile Implants Require a precertification for medical necessity. Prosthetics 90% 75% 80% Routine/Preventive Adults/Pregnant Women Well-Woman Visits (to receive services below for women under 65) Abdominal Aortic Aneurysm (one-time screening for men ages who have ever smoked) Alcohol Misuse Screening/Counseling Anemia Screening (on a routine basis fro pregnant women) Aspirin (To prevent cardiovascular disease for men ages & women ages 55-79) Blood Pressure Screening (for all adults) Breast Cancer Genetic Testing and Counseling (BRCA) (for women at higher risk of breast cancer, or with a personal history of non-brca related breast cancer or ovarian cancer) Deductible does NOT apply. Excludes premarital exams, college entrance, adoption or employment physicals, gym or sports and school physicals, as well as any exam of the teeth & gums.preventive Care Benefits include:(i) Services rated "A" or "B" by the U.S. preventive Services Task Force,(ii) immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention(iii) preventive care and screenings for women and children as recommended by the Health Resources and Services Administration**preventive Care Benefits provided by a Non-Network Provider will be 100% covered only if the particular item or service provided by the Non-Network Provider is not available form a Network Provider. Routine Exam

9 Breast Cancer Mammography Screening (every 1-2 years for women over 40) Breast Cancer Chemoprevention Counseling (for women at higher risk) Breastfeeding Comprehensive Support/Counseling (from trained provider for pregnant/nursing women) Breast Pump/Supplies (for pregnant and nursing women) Cervical Cancer Screening (PAP) (for sexually active women) Chlamydia Infection Screening (for younger women, and women at higher risk) Cholesterol Screening Colorectal Cancer Screening(Adults over age 50, including anesthesia if deemed necessary by the provider) Contraception (FDA approved contraceptive methods, Sterilization procedures, and patient education and counseling as prescribe by a health care provider for women with reproductive capacity. Not including abortifacient drugs. This does not apply to health plans sponsored by certain exempt "religious employers".) Depression Screening (for all adults) Diabetes (Type 2) Screening (for adults with high blood pressure)

10 Diet Counseling (for adults at higher risk of chronic disease) Domestic/Interpersonal Violence Screening/Counseling (for all women) Folic Acid Supplements (for women who may become pregnant) Gestational Diabetes Screening (for women who are weeks pregnant and those at high risk of gestational diabetes) Gonorrhea Screening (for all women at higher risk) Hepatitis B Screening (for pregnant women at first prenatal visit) HIV Screening (for everyone ages and those at high risk) Human Papillomavirus (HPV) DNA Test (every 3 years for women with normal cytology results who are 30 or older) Immunization Vaccines (For adults. Doses, recommended ages, and recommended populations vary) Hepatitis A & B, Herpes Zoster (shingles), Human Papillomavirus (Gardasil), Influenza (flu shot), Measles Mumps & Rubella (MMR), Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella (chicken pox) Obesity Screening/Counseling (for all adults)

11 Osteoporosis Screening(for women over age 60 depending on risk factors) Osteoporosis Screening (for women over age 60 depending on risk factors) Rh Incompatibility Screening (for all pregnant women and follow-up testing for women at higher risk) Sexually Transmitted Infection (STI) Prevention Counseling (for adults at higher risk & sexually active women) Syphilis Screening (for adults at higher risk, and sexually active women) Tobacco Use Screening (for all adults, and expanded counseling for pregnant tobacco users) Tobacco Cessation Interventions (for tobacco users. Also covered at a pharmacy through Rx benefits) Urinary Tract/Other Infection Screening (for pregnant women) Children Alcohol and Drug Use Assessments (for adolescents) Autism Screening (for children at 18 and 24 months) Behavioral Assessment (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years) All OTC and FDA Approved Rx, Two 90 Day regiments per year.

12 Blood Pressure Screening (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years) Cervical Dysplasia Screening (PAP) (for sexually active females) Depression Screening (for adolescents) Developmental Screening (for children under age 3) Dyslipidemia Screening (for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.) Fluoride Chemoprevention Supplements (for children without fluoride in water source) Gonorrhea Preventive Medication (for the eyes of all newborns) Hearing Screening (for all newborns) Height, Weight and Body Mass Index Measurements (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years) Hematocrit or Hemoglobin Screening (for children) HIV Screening (for adolescents at higher risk) Hypothyroidism Screening (for newborns)

13 Immunization Vaccines (for children from birth to age 18 doses, recommended ages, and recommended populations vary) Diphtheria, Tetanus, Pertussis, Haemophilus influenza type b, Hepatitis A & B, Human Papillomavirus (Gardasil), Inactivated Poliovirus, Influenza (Flu Shot), Measles, Meningococcal, Pneumococcal, Rotavirus, Varicella. Iron Supplements (for children ages 6-12 months at risk of anemia) Lead Screening (for children at risk of exposure) Medical History (for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years) Obesity Screening/Counseling Oral Health Risk Assessment (for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years) Phenylketonuria (PKU) Screening (for this genetic disorder in newborns) Sexually Transmitted Infection (STI) Prevention Counseling/Screening (for adolescents at higher risk) Tuberculin Testing (for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years)

14 Vision Screening (for all children) Skilled Nursing Facility 90% 80% 80% Smoking Cessation Sterilization See the Routine/Preventive Care section under Tobacco Cessation Voluntary (Male) 90% 75% 80% Requires Pre-certification Prior to 5/1/14: 120 days lifetime maximum Effective 5/1/14: 100 days per calendar year. Voluntary (Female) Under Routine/Preventive Care Reversal Not Covered Supplies 90% 75% 80% Surgery Dignity Health Elective Services. The Plan does not provide coverage for any elective services provided at a Dignity Health Hospital or Surgical Center. EFFECTIVE JANUARY 1, 2016 The above restriction will be removed as Dignity Health Hospitals will be considered a PPO provider. Claims with a date of service prior to 1/1/16 will still be considered out of network with the above restriction in force. Inpatient 90% 75% 80% Outpatient 90% 75% 80% Prior Auth required if sedated Office 90% 75% 80% Assistant Limited to 20% of the surgery allowance for primary surgeon. Anesthesia 90% 75% 80% CRNA 90% 75% 80% Second Opinion 100% 75% 80% Ambulatory Surgery Center 90% 75% 80% Prior Auth Required Multiple Surgeries Refraction Eye Surgery Therapy Industry Standard (Full/Half/Quarter/Eighth) for Non-Par claims. Not covered Physical/Occupational/Speech Therapy MUST be performed by a licensed therapist Physical 90% 80% 80%

15 Specialty meds Oncology/Rheumatoid arthritis Occupational 90% 80% 80% Speech 90% 80% 80% Prior to 5/1/14: Physical, Occupational and Speech Therapy is limited to a $4,000 calendar year max. Effective 5/1/14: 60 visit calendar year maximum. Available through the Medical plan when not readily available through the prescription drug program. Radiation 90% 80% 80% Chemotherapy 90% 80% 80% Hemodialysis 90% 80% 80% Cardiac Rehab 90% 80% 80% TMJ 90% 75% 80% Medical conditions only, not payable under the Dental Plan or billable by Dental providers Transplants ALL transplants must go thru Interlink Organ Transplant Network. All transplants require mandatory Case Management & must be performed at a Network facility thru the LifeTrac organ transplant network or Coalition (HSC) facilities, unless LifeTrac or HSC dose not offer the particular type of eligible transplant. Case Manager will determine whether transplant is medically necessary & appropriate for the patient's specific condition. Eligible expenses include those related to the allowable organ transplant, including patient screening, organ procurement, and transportation of the organ, patient and/or donor, surgery for the patient & donor, follow-up care in the home or Hospital. In no case will the Plan cover expenses for transportation of surgeons or family members. Organ 90% 75% 80% Bone Marrow and Stem Cell Not Covered. Donor 90% 75% 80% Donors [for an approved organ transplant on one of our members] are covered regardless if they are an eligible member in our plan, provided that such expenses are not payable by any other insurance or health plan.