2016/2017. Summary of Benefits

Transcription

1 2016/2017 Summary of Benefits

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3 Nondiscrimination Notice UPMC Health Plan 1 complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. UPMC Health Plan 1 does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. UPMC Health Plan 1 : Provides free aids and services to people with disabilities so that they can communicate effectively with us, such as: o o Qualified sign language interpreters. Written information in other formats (large print, audio, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as: o o Qualified interpreters. Information written in other languages. If you need these services, contact the Civil Rights Administrator. If you believe that UPMC Health Plan 1 has failed to provide these services or has discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Administrator UPMC Health Plan 600 Grant Street - 55 th Floor Pittsburgh, PA Phone: (TTY: ) Fax: HealthPlanCompliance@upmc.edu You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Civil Rights Administrator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, TTY/TDD users should call Complaint forms are available at 1 UPMC Health Plan is the marketing name used to refer to the following companies, which are licensed to issue individual and group health insurance products or which provide third party administration services for group health plans: UPMC Health Network Inc., UPMC Health Options Inc., UPMC Health Coverage Inc., UPMC Health Plan Inc., UPMC Health Benefits Inc., UPMC for You Inc., and/or UPMC Benefit Management Services Inc.

4 Translation Services ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. الصم والبكم: (. اتصل برقم )رقم هاتف ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). સ ચન : જ તમ ગ જર ત બ લત હ, ત નન:શ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: ). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). ប រយ ត ន បរ ស នជ អ នកន យ យ ភ ស ខ ម រ, បសវ ជ ន យខ នកភ ស ប យម នគ ត ឈ ន ល គ អ ចម នស រ រ រ បរ អ នក ច រ ទ រស ព ទ (TTY: ) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: ).

5 UPMC for Kids Summary of Benefits UPMC for Kids is available through a contract with the Children s Health Insurance Program (CHIP) of Pennsylvania. This is a state and federally funded program to provide health insurance for uninsured children and teens until they become age 19. Based on income, members are enrolled in either free CHIP, low-cost CHIP, or full-cost CHIP. The benefits are the same for the free, low-cost, and full-cost CHIP groups; only the copayments differ. There are no copayments for free CHIP. There are copayments for low-cost and full-cost CHIP. The copayments vary for these two groups. Members are assigned to the appropriate groups based on income as determined by the Pennsylvania Department of Human Services. Benefits are based on a plan year that begins on August 1. All services must be provided by a UPMC for Kids participating provider, except for emergency care. Some services must be prior authorized by UPMC for Kids. The benefits are described below: A. Hospital Services Medical, surgical, mental health, skilled nursing, and rehabilitation admissions $0 copayment Pre-admission testing is covered as part of the admission. Transplants are covered, except those that are considered experimental. Physician services for surgery, surgical assistant, and anesthesia services are covered. Administration of blood or blood products while in the hospital is covered. A semiprivate room is covered. A private room is covered if it is medically necessary and appropriate. Inpatient substance abuse detoxification admission $0 copayment Substance abuse inpatient rehabilitation and non-hospital residential services $0 copayment B. Emergency Department Visits Coverage for emergency department visits is determined under the prudent layperson standard, which is defined as: A sudden onset of a medical condition with symptoms that are of such severity, or pain that is severe enough, that someone who has an average knowledge of health and medicine could reasonably expect that not receiving immediate medical attention could result in: Placing the health of the member in serious jeopardy (in respect to a pregnant woman, the health of the woman or her unborn child). Serious impairment of bodily functions. Serious dysfunction of any bodily organ or part. Copayments for emergency department visits are listed below: No copayment $25 (waived if admitted) $50 (waived if admitted) 1

6 Ambulance service $0 copayment Ambulance service is covered when using a specially equipped vehicle used only for transporting the sick and injured. Ambulance services are covered when provided to transport a member to the nearest hospital able to treat the condition, between hospitals, and between hospitals and skilled nursing facilities. C. Urgent Care Visits Urgent care centers provide access to medical treatment when a UPMC for Kids member is sick or injured during hours when a primary care physician (PCP) is not available. Physicians and nurse practitioners at urgent care centers evaluate and treat urgent medical conditions. An urgent medical condition is any illness, injury, or severe condition which, under reasonable standards of medical practice, would be diagnosed and treated within a 24-hour period and, if left untreated, could rapidly become a crisis or emergency medical condition. No appointment or referral is needed to visit a participating UPMC for Kids facility. The copayments for urgent care visits are listed below: No copayment $10 copayment $25 copayment D. Out-of-Area Urgent Care Coverage is provided if a UPMC for Kids member is traveling outside our service area and has an urgent medical condition that requires medical attention before returning to the area. An urgent medical condition is any illness, injury, or severe condition which, under reasonable standards of medical practice, would be diagnosed and treated within a 24-hour period and, if left untreated, could rapidly become a crisis or emergency medical condition. Additionally, it includes situations in which a person s discharge from a hospital would be delayed until services are approved, or in which a person s ability to avoid hospitalization depends upon prompt approval of services. UPMC for Kids does not cover routine care outside our service area. The copayments for out-of-area urgent care visits are listed below: No copayment $10 copayment $25 copayment 2

7 E. Doctor Visits Primary care physician Preventive and sick care, including the following: Routine physical exams Well-child checkups Sick visits Covered diagnostic tests performed in the office Immunizations Hospital visits* *Copayments apply to office visits, not visits in the hospital. $0 copayment for preventive services, which include well-child care, lab tests, and immunizations $0 copayment for preventive services, which include well-child care, lab tests, and immunizations $0 copayment for preventive services, which include well-child care, lab tests, and immunizations $0 copayment for sick visits $5 copayment for sick visits $15 copayment for sick visits Specialist Office visits Covered diagnostic tests performed in the office Outpatient surgery Hospital visits* Surgery in the hospital A referral from the PCP is not needed to see a participating specialist. The PCP should know that the member is going to the specialist so the PCP can coordinate the care. *Copayments apply to office visits, not visits in the hospital. $0 copayment for specialist visits $10 copayment for specialist visits $25 copayment for specialist visits 3

8 Obstetrician-Gynecologist Annual gynecological exam Breast exam Maternity care for pregnancy prenatal and postpartum visits Other office visits Pap test Family planning and counseling services Covered diagnostic tests performed in the office Outpatient surgery (counts toward 50-visit limit) Hospital visits* A referral from the PCP is not needed to see a participating obstetrician-gynecologist. The PCP should know that the member is going to the ob-gyn so the PCP can coordinate the care. Copayments will be based on the physician s being noted as either a primary care physician or a specialist. If noted as a primary care physician, the lower PCP copayment will apply. If noted as a specialist, the higher specialist copayment will apply. *Copayments apply to office visits, not visits in the hospital. $0 copayment for routine gynecological visits $0 copayment for other gynecological visits $0 copayment for routine gynecological visits $5 or $10 copayment for other gynecological visits $0 copayment for routine gynecological visits $15 or $25 copayment for other gynecological visits $0 copayment for maternity visits $0 copayment for maternity visits $0 copayment for maternity visits Allergy services $0 copayment Allergy serum Diagnostic testing for allergies Allergy injections Hearing care services $0 copayment Covered every two years: One routine hearing examination and one audiometric examination per year Hearing aids and fittings (one per ear every two years) F. Outpatient Behavioral Health Services Outpatient behavioral health visits: Outpatient behavioral health sessions Medication checks Group therapy Intensive outpatient (IOP) sessions Partial hospitalization sessions Neuropsychological and psychological testing 4

9 $0 copayment per visit $0 copayment per visit $0 copayment per visit Outpatient substance abuse rehabilitation services: $0 copayment per visit $0 copayment per visit $0 copayment per visit G. Autism Spectrum Disorders UPMC for Kids covers all eligible members for the diagnostic assessment and treatment of autism spectrum disorders. The following services, when medically necessary for the assessment/treatment of autism spectrum disorders, are covered: Prescription drug coverage Services of a psychiatrist and/or psychologist Rehabilitative care and therapeutic care Coverage under this section shall be subject to copayment and any other general exclusions or limitations listed in your UPMC for Kids Exclusions booklet. Treatment of autism spectrum disorders must be: Identified in a treatment plan Prescribed, ordered, or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker, or certified registered nurse practitioner Provided by an autism service provider or a person, entity, or group that works under the direction of an autism service provider The following definitions apply to this benefit: Autism service provider Means any of the following: 1. a person, entity, or group providing treatment of autism spectrum disorders, pursuant to a treatment plan, that is licensed or certified in the Commonwealth of Pennsylvania; and 2. any person, entity, or group providing treatment of autism spectrum disorders, pursuant to a treatment plan, that is enrolled in the Commonwealth of Pennsylvania s Medical Assistance program on or before July 1, Autism spectrum disorders Any of the pervasive developmental disorders defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), or its successor, including autistic disorder, Asperger s disorder, and pervasive developmental disorder not otherwise specified. X X Treatment plan A plan for the treatment of autism spectrum disorders developed by a licensed physician or licensed psychologist pursuant to a comprehensive evaluation or re-evaluation performed in a manner consistent with the most recent clinical report or recommendations of the American Academy of Pediatrics. 5

10 Upon denial or partial denial by an insurer of a claim for diagnostic assessment of autism spectrum disorders or a claim for treatment of autism spectrum disorders, a UPMC for Kids member or an authorized representative shall be entitled to an expedited internal review process followed by an expedited independent external review process established and administered by the Insurance Department. You or an authorized representative may appeal to a court of competent jurisdiction for an order of an expedited independent external review disapproving a denial or partial denial. Pending a ruling of such court, we shall pay for those services, if any, that have been authorized or ordered until the ruling is made. H. Outpatient Services Chiropractic services Up to 20 therapeutic manipulation visits per benefit year, including consultation, x-rays, and other tests necessary in the treatment plan. Prior authorization must be obtained for children 13 years of age or younger. $0 copayment per visit $10 copayment per visit $25 copayment per visit Clinical trials and research studies copayments apply to services where applicable Routine clinical services available under this benefit plan that are part of a clinical trial or research study approved by an Institutional Review Board as well as medically necessary services to treat complications arising from participation in the clinical trials and studies. These services must be pre-authorized by the Health Plan, and all plan limitations apply. Diabetic education $0 copayment Gender Transition Services Coverage related to gender transition services, that otherwise falls within the scope of covered CHIP benefits (e.g., physician s services, inpatient and outpatient hospital services, prescribed drugs, therapies) when determined medically necessary. Some services may require prior authorization. Imaging studies $0 copayment X-rays and sonograms Advanced imaging services, such as MRIs, CT scans, and PET scans Laboratory tests $0 copayment Maternity education $0 copayment Lamaze classes, initial and refresher Parenting classes Breastfeeding classes Doula nonmedical childbirth support (available with participating providers) Medical nutritional therapy $0 copayment Provided by a dietitian or facility-based program, when ordered by a physician for certain diagnoses to treat chronic illnesses or conditions 6

11 Medical therapy services $0 copayment Chemotherapy Radiation therapy Dialysis Respiratory therapy Infusion therapy Nutritional counseling $0 copayment Provided by a dietitian or facility-based program, when ordered by a physician for any diagnosis Occupational, physical, and speech therapy Limited to 60 visits per therapy type per plan year. Habilitative therapy services are covered. Visit limits under the habilitative therapy benefit are combined with limits for regular occupational, physical, and speech therapy visits. $0 copayment per visit $10 copayment per visit $25 copayment per visit Outpatient surgery $0 copayment Some procedures may require prior authorization. Pain management $0 copayment Tobacco cessation counseling $0 copayment Limited to 50 visits per plan year. PCPs may also provide this service. Voluntary sterilization $0 copayment I. Home Care Services Home health $0 copayment Includes home nursing visits Private duty nursing (requires prior authorization from UPMC for Kids) Limited to a maximum of 16 hours per day Hospice care $0 copayment When medically necessary J. Equipment and Supplies Corrective appliances $0 copayment Orthotics Shoe inserts and orthopedic shoes for diagnosis of diabetes Prosthetic devices Prior authorization from UPMC for Kids required for some appliances 7

12 Diabetic supplies obtained through pharmacy Glucometers Test strips Lancets Insulin Syringes $0 copayment for generic drugs $6 copayment for generic drugs $10 copayment for generic drugs $0 copayment for brand-name drugs $9 copayment for brand-name drugs $18 copayment for brandname drugs Durable medical equipment $0 copayment When medically necessary Prior authorization from UPMC for Kids required for some services Enteral/Parenteral feedings $0 copayment Limited to treatment of certain conditions (For specific conditions, please see the Nutritional Supplements section of the UPMC for Kids Exclusions booklet.) Requires prior authorization from UPMC for Kids K. Pharmacy UPMC for Kids provides coverage for prescription drugs and some over-the-counter drugs. The UPMC for Kids Pharmacy Benefits formulary must be followed. More information is included in the UPMC for Kids Pharmacy Benefits brochure. Prescription drugs Coverage for brand-name drugs and generic drugs. A generic drug will be substituted for a brand-name drug when a generic is available. If the physician indicates that a brand-name drug is necessary, the request must be reviewed by UPMC for Kids. UPMC for Kids allows the brand-name drug at the generic cost-sharing rate if deemed medically necessary by the provider. Mail order available for chronic drugs. Some special drugs used to treat complex medical conditions should be ordered from the UPMC for Kids specialty drug provider. Pharmacy prescription drugs one-month supply $0 copayment for generic drugs $6 copayment for generic drugs $10 copayment for generic drugs $0 copayment for brand-name drugs $9 copayment for brand-name drugs $18 copayment for brand-name drugs Mail-order prescription drugs three-month supply 8

13 $0 copayment for generic drugs $12 copayment for generic drugs $20 copayment for generic drugs $0 copayment for brand-name drugs $18 copayment for brand-name drugs $36 copayment for brand-name drugs Over-the-counter drugs Coverage for formulary medications that can be purchased without a prescription. Examples are vitamins, pain relievers, and tobacco cessation products. Covered only if the physician writes a prescription for the over-the-counter drug. $0 copayment for generic drugs $6 copayment for generic drugs $10 copayment for generic drugs $0 copayment for brand-name drugs $9 copayment for brand-name drugs $18 copayment for brand-name drugs Up to a 30-day supply can be provided for retail medications, specialty medications, and controlled substances. Mail order may be used for chronic or ongoing medications for up to a 90-day supply, except for specialty medications, over-the-counter medications, and controlled substances. Based on the type of medication, the number of refills may vary. The maximum period for refills is one year from the date of the original prescription. L. Dental Services UPMC for Kids covers many dental services, including preventive care and other services. A participating dentist must be used. There are no copayments for routine dental services; however, if any dental service is provided under the medical benefit, a copayment may apply. The types of dental services covered are: Preventive and diagnostic services: Two routine exams per year, including cleaning of teeth, one checkup every six months, with the exception of a member under the care of a medical professional for pregnancy, who shall be eligible for one additional cleaning during pregnancy. Two topical fluoride treatments per year (one treatment every six months). Two topical applications of fluoride varnish per year. Services can be provided by either a dental provider or a PCP. Sealants for members less than 19 years of age for permanent molars free from caries and/or restoration. One sealant per tooth every three years, except when visible evidence of clinical failure is apparent. Dental x-rays: Full mouth x-rays limited to once in a three-year period. Bitewing x-rays limited to once in a six-month period. Space maintainers. 9

14 Other services: Anesthesia when done with a covered service Bridges Crowns (prior authorization from UPMC for Kids required for some crowns) Dentures limited to one set per 60 months Emergency temporary treatment of an acute dental condition requiring immediate care Fillings amalgam and resin-based composite restorations Major restorative services Minor restorative services Occlusal guard by report one in 12 months Pedicle soft tissue grafts Periodontal services Prosthodontic services Pulpotomies Removal of impacted teeth (soft tissue, partial, and bony impactions) Root canals Simple extractions Orthodontia (braces)*: (Not for cosmetic reasons, only when medically necessary) Evaluations for braces: Only covered as a separate service if the member is determined to be ineligible for other orthodontic services Limited to once per benefit period Placement of braces, adjustments, and removal Retainers limited to one; replacements are not covered *Requires prior authorization by UPMC for Kids M. Vision Services Visits for routine eye exams and glasses or medically necessary contacts are covered. There are no copayments for the routine vision services below. Eye care services provided under the medical benefit will have applicable copayments. A participating vision provider must be used. Eye exam $0 copayment One routine eye examination once in a 12-month period 10

15 Prescription lenses and frames or contact lenses $0 copayment Allowance of up to $130 in a 12-month period for: Prescription lenses and frames or contact lenses (including the lens fitting) Adjustments to frames for up to 90 days after receiving glasses Replacement of broken, lost, or scratched corrective lenses (when replacement is deemed medically necessary), not to exceed two prescriptions per year Lenses: One pair of standard lenses are covered in full every calendar year Additional charges may apply for nonstandard lenses that would become the responsibility of the member Contact lenses: One prescription every year in lieu of eyeglasses or when medically necessary for vision correction Expenses in excess of a $130 allowance (may be applied toward the cost of evaluation, materials, fitting, and follow-up care) payable by member; additionally, a 15% discount for any amount over $130 Frames: Allowance of up to $130 in a 12-month period Expenses in excess of $130 allowance payable by member; additionally, a 20% discount for any amount over $130 Low vision $0 copayment One comprehensive low vision evaluation every five years, with a maximum charge of $300; maximum low vision aid allowance of $600 with a lifetime maximum of $1,200 for items such as high-power spectacles, magnifiers, and telescopes; and follow-up care four visits in any five-year period, with a maximum charge of $100 per visit. Providers will obtain the necessary pre-authorization for these services. Vision services for a medical condition $0 copayment Prescription lenses and frames and the fitting and adjustment of contact lenses are covered for a diagnosis of cataracts, keratoconus, or aphakia. The $130 allowance does not apply for these conditions. They are covered in full. N. Additional Services and Programs There are no copayments for the services below unless noted. Care management programs: To help members and their families manage their health for some conditions, we have several programs. Participation in these programs is voluntary: Asthma Diabetes Maternity Seizures Smoking: To help our members to stop smoking or using tobacco, we provide education on what they can do to stop. See benefits for smoking cessation counseling (50 counseling sessions per year) and over-the-counter products for tobacco cessation. (Copayments for tobacco cessation medications apply as noted in the Pharmacy section.) 11

16 Obesity: Focus on a healthy lifestyle for members and their families PCP can provide information on diet and exercise See nutritional counseling benefit See MyHealth Rewards program for discounts on membership in gyms and other activities MyHealth Rewards: A program that offers discounts that help to promote healthy and active lifestyles for children and their families UPMC MyHealth 24/7 Nurse Line: Available 24 hours a day/7 days a week, the UPMC MyHealth 24/7 Nurse Line is open to answer your health care questions. A registered nurse will help you when you call UPMC MyHealth OnLine: CHIP membership with UPMC for Kids includes access to MyHealth OnLine. With this secure, easy-to-use website, you have 24/7 access to your most current information. You can: u Review your benefits and copayments. u View and pay your bills (low-cost and full-cost CHIP members). u Search for doctors and pharmacies. u See what prescription drugs your plan covers. u Find discounts and savings through participating business, including gyms, spas, and health food stores. u Discover health care resources for infants, adolescents, and teens. u Chat online with a Member Services Health Care Concierge. This service is an enhanced benefit for CHIP members, brought to you by UPMC for Kids. O. Services Not Covered Some services are not covered by UPMC for Kids, and some services that are covered may have limitations. See a separate document titled UPMC for Kids Exclusions for a list of noncovered services. 12

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20 This managed care plan may not cover all of your health care expenses. Read all of your materials carefully to determine which health care services are covered. UPMC for Kids Health Care Concierge Team: TTY Services: U.S. Steel Tower, 600 Grant Street Pittsburgh, PA Copyright 2017 UPMC Health Plan Inc. All rights reserved. CHIP SOB 17CHIP0101 HL (SHD) 6/8/17