Frequently Asked Questions Traditional Care Network (TCN)

Transcription

1 Frequently Asked Questions Traditional Care Network (TCN) TCN Question: Are vitamin B-12 shots a covered benefit? Answer: B-12 injections are not a covered benefit. TCN Question: Could you please explain what are deductibles, co-payments, coinsurance, and out-of pocket maximums? Answer: A deductible is the amount a member must pay towards covered medical services within a given year before the Plan begins paying. Co-payments are fixed dollar amounts paid by the member for a covered medical service. Co-payments are on- going and do not count towards your deductibles. An example would be urgent care. A visit to the urgent care center is $ Coinsurance is the percentage/amount a member must pay toward covered medical services, after the deductible is met. For example, if you had inpatient hospital services your cost share would be 10% of the allowed amount for an in-network provider and 30% for an out-of network provider. The plan and the member share the cost of covered medical services until the out-of-pocket maximum is met for the calendar year. Out-ofpocket maximums are the total dollar amount a member must pay toward covered medical services in any calendar year. This includes both the deductible and coinsurance amounts. Once the out of pocket maximum is met, all covered medical services will be paid by the plan at 100% for the remainder of that calendar year. TCN Question: Are Shingles vaccines a covered benefit by TCN or Express Scripts? Answer: If a TCN member has Medicare Part D, their shingles benefit is administered through Express Scripts as well as the TCN medical plan. If members choose to go to the Pharmacy, they will be responsible to pay the Express Scripts Tier 2 co-payment. If the member chooses to use the medical plan they can go to their physician s office (office visit co-payment may apply). They may also use a Participating Pharmacy. If the Pharmacy does not participate or is unable to bill BCBS and the member pays up front for the vaccine the member may seek reimbursement by sending in an itemized receipt to the address below. Do not use the health department for your vaccinations/shots. For non-medicare members: You can obtain the shot at a Blues-participating pharmacy with no co-pay by using your BCBS ID card. If the member uses a pharmacy that does not participate with the Blues (you have no co-pay, but you may have to pay up front and seek reimbursement) they must submit an itemized receipt to: BCBSM UAW Auto Retiree Service Center PO Box Detroit, MI TCN Question: Are pneumonia and flu vaccines covered by TCN or Express Scripts? Answer: For Medicare and non-medicare members these vaccines are covered by the medical plan only. They are a benefit in your in-network doctor s office (office visit co-pay may apply if other medical services are rendered). You are not covered if you get your shot outside a network doctor s office. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

2 TCN Question: Are gym benefits available? Answer: BCBS has a program that offers healthy discounts including some fitness clubs; it is called healthybluextras for Michigan and nationally Blue365. I have a flyer that offers additional information on these discounts. TCN Question: What is covered for routine vision services? Answer: In 2012, a routine vision benefit was provided through your medical plan. The vision exam covers one routine eye exam every 24 months; it is covered with a $25.00 co-payment. Hardware is not included in the coverage does not include coverage for glasses or contacts. Routine vision services are not subject to the deductible and out-of-pocket maximums. TCN Question: What is covered under medical eye services? Answer: Medical visits by a physician for the examination, diagnosis, and treatment of any eye condition, disease, or injury to the eye. Examples of medical eye conditions are glaucoma and cataract removal. Prescription lenses (eyeglasses or contact lenses) only following a cataract operation for any disease of the eye or to replace the organic lens missing because of the congenital absence, or when customarily used during convalescence from eye surgery are covered. TCN Question: What happens at age 65 as far as Medicare eligibility and processing? Answer: Enrollment for Medicare begins 3 months prior to your 65 th birthday and ends 3 months after your birthday. Medicare Part A is assigned, it is very important to enroll in Medicare Part B; your benefits will be paid with Medicare being primary and the Traditional Care Network as your secondary insurance. TCN Question: How do I find providers that are contracted with the plan? Answer: One way is online -the BCBS website has recently been redesigned and the participating provider search function and directory have been enhanced. I have an informational flyer available on Finding a Doctor or Hospital with more detailed instructions. You can also contact BCBS Customer Service at to find out if you physician participates in your plan. TCN Question: (General Motors and Chrysler only) What is my benefit for Hearing Aids? Answer: Services must be obtained from participating providers. An ear specialist (otologist or otolaryngologist) must first examine you. This is to determine if your hearing loss is caused by a condition that may be corrected by the use of a hearing aid. One audiometric exam, a hearing aid evaluation test and one standard hearing aid will be covered once every 36 months. Hearing aid services are not subject to the deductible and out-of-pocket maximums. 2

3 TCN Question: (Ford Motor Company only) What is my benefit for Hearing Aids? Answer: Your hearing aid services are provided through SVS/AudioNet Hearing Aid Services, their toll free number is Hearing aid services are not subject to the deductible and out-of-pocket maximums. TCN Question: What is my office visit co-payment? Answer: For non-medicare members as of 2015, there are six (6) routine (not extensive) office visits covered with a $25.00 co-payment for each person on the contract conducted in a physician s office setting. The visits must be obtained from an in-network provider. Covered providers include Family Practice, General Medicine, Internal Medicine, Geriatrician, OB/GYN, Pediatrician, Nurse Practitioner, and Physician Assistant. Specialists are not covered under this benefit. For Medicare members, the office visit is paid by Medicare at 80% and the member is responsible for the remaining 20%. Office visits are not subject to the deductible and out-of-pocket maximums. TCN Question: Who do I contact if I need a replacement TCN ID card? Answer: Contact the TCN customer service center at (this number is located on the back of your BCBS ID card) for your BCBS ID card. If a member calls BCBS for an Express Scripts ID card, they will be assisted by BCBS Customer Service in reaching Express Scripts to resolve their concern. They may also call Express Scripts directly at for a replacement ESI ID card. TCN Question: Do I have coverage for ground ambulance services? Answer: Yes, coverage is provided when necessary and consistent with the treatment of an illness or injury and is appropriate given the patient s circumstances and condition, ambulance transportation (including by ground, air or boat ambulance) to the closest available facility qualified to treat the patient if the following conditions are met: 1) Ambulance services are not medically necessary if any other means of transportation could be used without endangering the patient s health. TCN Question: Am I covered for emergency medical care? Answer: Yes, if you experience a traumatic injury or a life-threatening condition that requires immediate medical attention. A medical emergency will be considered to exist only if medical treatment is secured within 72 hours after the onset of the condition. There is $ emergency room co-payment; the co-payment will be waived if you are admitted into the hospital. First aid emergency services (for example an ankle sprain) would be subject to the $ emergency room copay. This co-payment is not subject to the deductible and out-of-pocket maximums. Also, covered emergency room services are not subject to deductibles and out-of-pocket maximums. If admitted to the hospital, the inpatient hospital charges will be subject to the deductible, co-insurance, and out of pocket maximum cost share. 3

4 TCN Question: Am I covered for urgent care services? Answer: Yes, in-network Urgent Care Facilities are covered and can provide care for certain medical conditions requiring urgent attention. There is a $50.00 co-payment for urgent care services. There is no coverage for out-of-network Urgent Care Facilities. This co-payment is not subject to the deductible and out-of-pocket maximums TCN Question: If I travel outside of the United States, what medical services are covered? Answer: Outside of the United States, you have access to doctors and hospitals in more than 200 countries and territories through the BlueCard Worldwide program. Always carry your current Blues ID card. In an emergency, go directly to the nearest hospital. If you need medical, assistance services call the BlueCard Worldwide Service Center at BLUE (2583) or call collect at , 24 hours a day seven day a week. You may need to pay for services up front and submit the bills for evaluation. You will only be reimbursed for covered services (deductibles, co-payments and coinsurance still apply). TCN Question: Does TCN cover toenail clipping at a Podiatrist s office? Answer: Expenses for routine foot care (including, but not limited to, trimming of toenails, removal or reduction of corns and calluses, removal of thick/cracked skin on heels, foot massage, preventive care with assessment of pulses, skin condition and sensation), or hand care including manicure and skin conditioning are not covered. However, routine foot care from a podiatrist is covered for individuals with diabetes or a neurological or vascular insufficiency affecting the feet. 4

5 Express Scripts Frequently Asked Questions ESI Question: I have received numerous Express Scripts ID Cards not sure which one I should use. Answer: Utilized the Express Scripts tool given to us by the URMBT to help the member determine which ID was the correct card to use. Also, give Express Scripts member services phone number (866) to answer additional questions for the member. ESI Question: I have not received my Express Script ID Card. Answer: Please call Express Scripts member services phone number (866) to order an Express Scripts ID card. ESI Question: I accidentally threw out the booklet (Drug Formulary for Tier Level of drug) that I received from Express Scripts. Answer: To request another copy of the formulary, call the Express Scripts (gave to member) the member services phone number (866) to request an additional copy. TCN Question: Do I have coverage for DME (Durable Medical Equipment) and P & O (Prosthetic and Orthotic) Appliances? Answer: Yes, coverage is provided for DME and P &O that are medical in nature and prescribed by your doctor. DME and P&O appliances must be obtained from an in-network provider. If covered items and services are received from out-of-network providers, you will be responsible for paying the provider including additional amounts up to the provider s full charges for the supply or services. DME and P & O are not subject to the deductible and out-of-pocket maximums. Note: Medicare members may use a Medicare approved supplier for DME and P & O. DME and P & O General Guidelines DME is defined as in-home use of basic medical equipment or medical appliances. Coverage for a prosthetic or orthotic appliance includes the replacement, repair, fitting, and adjustment of the appliance. Durable Medical Equipment includes: Respirator Equipment (ex. Oxygen and CPAP Continuous Positive Airway Pressure machine), Pressure Gradient Supports (ex. Jobst Stockings) Medical Supplies, Commodes, Walkers, Canes, Neuromuscular Stimulators, Wheelchairs and Hospital Supplies. Prosthetic Appliances includes: Wigs and related supplies for enrollees suffering hair loss from the effects of chemotherapy or radiation treatment. Also covered are Artificial Limbs, Breast Prosthesis, and Mastectomy Bras. Orthotic Appliances includes: Orthotic Shoes, Arch Supports, Inserts, and Shoe Modifications (as part of a brace). Diabetic Equipment & Supplies Coverage 5

6 There may be limits on how often you can get these supplies or how much you can get at one time. Materials for testing blood sugar (glucose) include: Self-Testing Monitor, Test Strips and Lancet Devices. (Note: Needles and Syringes are covered through the pharmacy benefit Express Scripts) Diabetic Therapeutic Shoes (Eligible for 1 pair of shoes per calendar year) Choose one of these options: One pair of depth-inlay shoes and three pairs of inserts One pair of custom-molded shoes (including inserts) and 2 additional pairs of inserts (if you can t wear depth-inlay shoes because of a foot deformity) Medicare Part D changes: Effective July 1, 2013 the National Mail Order Program as mandated by CMS (Centers for Medicare and Medicaid Services) will begin for diabetic testing supplies. All Medicare primary members will need to utilize an approved Medicare provider. This means that their current diabetic testing supplier may no longer be an approved provider. FYI: Earlier this year Medicare began a Competitive Bidding Program for DME suppliers in many areas of the country as well as implementing a National Mail Order Program for diabetic testing supplies. This program will change the way Medicare pays suppliers for certain durable medical equipment and mail order diabetic testing supplies and will make changes to who can supply these items. TCN Question: Is my bone mass measurement (bone density) test covered? Answer: Yes, it is covered if you are at risk or are diagnosed with osteoporosis once every 24 months or more often if medically necessary, which is determined by your physician. This service is not subject to cost sharing when prescribed by an In-Network Physician and administered by an In-Network Provider. TCN Question: (General Motors and Chrysler only) I have the TCN plan do I have physical therapy benefits? Answer: Up to 60 combined visits (per qualifying condition) per calendar year are covered for outpatient physical, functional occupational and/or speech therapy provided by an in-network hospital or by an in-network approved Freestanding Outpatient Therapy Facility, Home Health Care Agency, Skilled Nursing Facility or independent physician or therapist participating with and approved by TCN. The 60-visit annual limit (per qualifying condition) may be renewed after surgery or a definite aggravation of the condition. These services are subject to the deductible, co-insurance, and out-ofpocket maximums. Physical, functional occupational or speech therapy benefits will NOT be paid if received from a Provider that is out-of-network. 6

7 TCN Question: (Ford Motor Company only) I have the TCN plan do I have physical therapy benefits? Answer: TheraMatrix Physical Therapy Network administers outpatient physical therapy benefits. This benefit applies only to in-network providers. Physical therapy benefits will not be paid if received from a provider that is not in the network. Contact TheraMatrix at to find an in-network participating provider. You may also access their web site at TCN Question: Do I have benefits for Skilled Nursing Facility Coverage? Answer: Yes, see below. URMBT Skilled Nursing Facility (SNF) Benefit Change Effective 01/01/12, the SNF benefits for the URMBT group was changed to reflect maximum coverage of 100 days, which is renewed on January 1st of each year. URMBT Benefit Period Guidelines The SNF 100 day benefit change for URMBT is only renewable on January 1 of each year and after each new benefit period. A new SNF 100 day benefit period begins when the member has been out of a SNF setting for 60 consecutive days from the last date of discharge and the date of the next admission and every January 1. Group Processing Guidelines The maximum number of Medicare coinsurance days are 80 and should be used when counting days paid by BCBSM as the secondary carrier. ***Adjudicators will continue their current process of validating if the 80 coinsurance days has been exhausted. Example: Benefit Period SNF Stay 100 days Coverage Breakdown 06/01/12 06/20/12 Medicare pays 20 days in full as primary 06/21/12 06/30/12 BCBSM pays 10 coinsurance days as secondary 07/01/12 07/31/12 BCBSM pays 31 coinsurance days as secondary 08/01/12 08/31/12 BCBSM pays 31 coinsurance days as secondary 09/01/12 09/08/12 BCBSM pays the remaining 8 coinsurance days as secondary 09/09/12 09/30/12 22 days is the member s liability (reject X212) If the member has exhausted benefits (100 days) within the same year, they are liable for the remaining days beyond the 100-day benefit. ***Adjudicators must follow the procedural instructions housed in condition code M216. If the benefit period carryover to the following year, then the URMBT maximum benefit of 100 days will automatically renew on January 1st. 7

8 Example: Benefit Period SNF Stay 100 days Coverage Breakdown 11/01/12 11/20/12 Medicare pays 20 days in full as primary. 11/21/12 11/30/12 BCBSM pays 10 coinsurance days as secondary. 12/01/12 12/31/12 BCBSM pays 31 coinsurance days as secondary. **01/01/13 01/31/13 BCBSM pays 31 coinsurance days as secondary. 02/01/13 02/08/13 BCBSM pays 8 coinsurance days as secondary. (Medicare 100 days has exhausted) 02/09/13 02/28/13 Precertification is required. (BCBSM becomes Primary and pays 20 days) ***03/01/13 03/31/13 BCBSM pays as primary 31 days. **On 01/01/13, the URMBT benefit of 100 days is renewed. ***Member has 10 days remaining in this period then days are exhausted. Precertification and recertification are required for every skilled nursing admission when BCBSM is primary, however it does not supersede the new URMBT benefit maximum. It only determines medical appropriateness. PPO Question: What are my benefits if I have Blue Preferred Plus PPO in Michigan or the PPO out of state (only applies to certain Chrysler and Ford Motor Retirees)? Answer: If you are a Chrysler Retiree your group number is and if you are a Ford Retiree your group number is to identify the benefits that you have. There are separate Benefits- At-A-Glance brochures available to identify the benefit differences. FYI Below is a list of URMBT Alpha Prefixes with Description and Group Number: Prefix URMBT Group Group Number UCK Chrysler Retiree TCN UDC Chrysler Retiree TCN full Medicare UIC Chrysler Retiree TCN St. Louis Only UDD Chrysler Retiree TCN full Medicare St. Louis Only UDQ Chrysler Retiree PPO St. Louis Only UDX Chrysler Retiree PPO full Medicare St. Louis Only UCC Chrysler Retiree PPO UCI Chrysler Retiree PPO full Medicare UFK Ford Retiree TCN UFL Ford Retiree TCN full Medicare UFQ Ford Retiree TCN St. Louis Only UFV Ford Retiree TCN full Medicare St. Louis Only UFG Ford Retiree PPO UFJ Ford Retiree PPO full Medicare UGD GM Retiree TCN UGG GM Retiree TCN full Medicare UGF GM Retiree TCN St. Louis Only UGP GM Retiree TCN full Medicare St. Louis only

9 TCN Question: Are Cochlear Implants a covered benefit? Answer: Yes, Medicare and the Trust cover them for members who are candidates. Candidacy is based on the medical diagnosis given by their doctor. TCN Question: Are diabetic education classes covered? Answer: Yes, when the member has been newly diagnosed with diabetes and for those with diabetes that are not well-controlled, as determined by a member s doctor. Diabetes Education classes consist of many components, one of them being education on nutrition; other components include foot care and insulin administration etc. Nutritional counseling alone is not a covered benefit for any diagnosis. TCN Question: How does my Auto Insurance coordinate with my health plan? Answer: Your Auto Insurance is primary, if the member has Medicare, then Medicare insurance is secondary and the TCN Supplemental insurance is third. For a non-medicare member the Auto insurance is primary and TCN is secondary. TCN Question: I went to the ER and thought I was admitted to the hospital (they put me in a room and I stayed overnight). Why did I have to pay the $ emergency room co-payment? Answer: The payment of $ was required because you were not considered admitted by the hospital; When you are NOT admitted it is considered Observation. It may seem to the member as if it was an admission because they ma y have been in the hospital for several days and moved out of the actual Emergency Room area into another room. However, unless the provider actually admits the member, it is considered observation. We recommend the member ask the doctor or the nurse, if they have actually been admitted. Additionally if you are in a Medicare Advantage PPO state, you can mention to the member that if they and their spouse or if they have dependents have Medicare Parts A and B they would be eligible for the Medicare Advantage PPO plan and the Emergency Room Copayment would only be $ *Note: New for Durable Medical Equipment March 2014 TCN Question: I have Medicare and I need Diabetic Supplies (DME), how do I find a contracted provider? Answer: Because Medicare is primary, you need to use a contracted Medicare approved supplier, you can locate one by calling Medicare at or go to website. You may also call BCBS DME phone number on the back of your ID card and they will assist you by transferring your call to Medicare to locate an approved provider. Medicare pays 80% of DME supplies, your BCBS will pay the remaining 20% of the DME charge as long as it is a Medicare approved supplier, and (they do not have to participate with BCBS to have the 20% paid). If you do not have Medicare, you must use a contracted BCBS participating provider, you can locate one by calling the DME phone number on the back of your BCBS ID card. 9

10 *Note: New FAQ s May 2014 Question: How can I locate a participating in-network Doctor, Hospital or Other Health Care Provider online? Answer: You can find at doctors, hospitals and other health care providers online. You can locate these providers based on location, quality scores and recognitions as well as how satisfied other patients have been. Providers can be found based on your current health plan by entering the zip code or city & state and doctor s name or by the type of provider specialty you are seeking. If you are having difficulty locating a participating in-network provider you may contact the Customer Service Phone number located on the back of your BCBS ID card. Question: Prolia Injections (for Post-Menopausal Osteoporosis) are they a covered benefit for (TCN) Traditional Care Network? Answer: Prolia falls under procedure code J0897, a standard injection. Although Medicare pays for standard injections including Prolia they are not covered by TCN. TCN only cover injections that are for chemotherapy, immunizations or surgical injections as well as infusion therapy. This does not fall under the criteria and this would not be covered. However, you can direct the member to Express Scripts and Prolia may be covered under that Plan. 10