Summary of Material Modifications (SMM) The Flexible Benefits Plan October 2015

Transcription

1 Summary of Material Modifications (SMM) The Flexible Benefits Plan October 2015 This notice details changes and clarifications to your Summary Plan Description that are effective January 1, 2016, unless otherwise noted below. You should keep this with your Flexible Benefits Plan Summary Plan Description (SPD) for reference. The terms of the plan are not changing and remain in effect, except as specifically described in this summary. In addition, certain required annual notices are provided below. Traditional Medical Option The annual deductible under the Traditional medical option for in-network and out-of-area services will increase to $300 individual and $600 family. The annual deductible for out-of-network services will increase to $600 individual and $1,200 family. Additionally, the annual out-of-pocket maximum for in-network and out-of-area services will increase to $2,500 individual and $5,000 family. The annual outof-pocket maximum for out-of-network services will increase to $5,000 individual and $10,000 family. These changes do not apply to employees living in Hawaii. UPS Healthy Advantage Medical Plan Option The Flexible Benefits Plan will offer a new medical option called UPS Healthy Advantage. This option is similar to the Healthy Savings option but has lower payroll deductions compared to the Traditional and Healthy Savings options. It is designed to work with a Health Savings Account (HSA) to offer employees more choice and flexibility. The table at the end of this SMM contains a more detailed summary of this Plan option. This option is not available to employees living in Hawaii. Although it is similar to the Healthy Savings option, UPS Healthy Advantage is different in some ways from the Healthy Savings option. See the table at the end of this SMM for differences between the two options. Also, the Healthy Advantage option is not a grandfathered plan option as defined by the Affordable Care Act (ACA). Thus, it is subject to the following additional terms and conditions: Approved Clinical Trials The Plan will not deny routine patient costs solely because they were incurred as part of an approved clinical trial. Routine patient costs include all items and services that are otherwise covered under this Plan with respect to covered individuals not 1 participating in an approved clinical trial. In other words, the Plan will not deny benefits for services or treatments solely because they are provided in connection with an approved clinical trial. Routine patient costs do not include: The investigational item, device, or service, itself Items and services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient An approved clinical trial means a phase I, II, III, or IV clinical trial conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition (a disease or condition for which death is probable unless the disease or condition is interrupted) of a covered individual and is one of the studies or investigations described below: The study or investigation is federally funded by one of the federal organizations identified in Section 2709(d)(1)(A) of the Public Health Service Act. The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration. The study or investigation is a drug trial that is exempt from having such an investigational new drug application. Coverage of Recommended Preventive Care Services and Treatments Recommended preventive services will also be covered in accordance with the ACA. The ACA requires group health plans to provide preventive care services in-network without cost sharing as follows: (i) evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force; (ii) immunizations for routine use in children, adolescents, and adults

2 that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (iii) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and (iv) with respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA. Reasonable medical management techniques may be imposed by the Claims Administrator where frequency and duration are not specifically addressed in the guidelines. For a general list of recommended preventive services required by the ACA, refer to the following website: 07/preventive-services-list.html Additional Appeals Rights and Obligations In addition to the general rights and obligations you have under the Plan with respect to appeals of any adverse benefit determinations, the following additional rights and obligations apply to appeals of adverse benefit determinations: You have the right to request diagnosis and treatment codes (and their corresponding meanings). The information necessary to request such codes will be included in your denial letter. You may review the claim file and present evidence and testimony at each state of the appeals process. The appeal letter will include the contact information for any applicable health care consumer assistance organization in your state. You may request, free of charge, any new or additional evidence considered, relied upon, or generated by the plan in connection with your claim. If at any level of appeal a decision is made based on a new or additional rationale, you will be provided with the rationale and be given a reasonable opportunity to respond before a final decision is made. You may make a written request for an external review with an independent review organization within four months of the date you receive a second-level denial from the UPS Claims Review Committee that is based on medical judgment or rescission of coverage. Also, you may request an external review for a denial of an Urgent Care Claim based on medical judgment or rescission of coverage provided that the time frames for completion of an urgent care appeal will seriously jeopardize your life or health or would seriously jeopardize your ability to regain maximum function. Within five business days of receiving your request for an external review, the Claims Review Committee or its designated representative will complete a preliminary review of the request to determine whether you were covered under the Plan at the time the expense was incurred and whether you have exhausted the internal appeal process where required. Within one business day of making the determination, you will be notified if the external review request is denied and you will be provided with (i) the reasons why the claim is initially ineligible for external review, or (ii) the information or materials needed for a complete request. In the event your request is denied due to lack of information or materials, you must perfect your claim by the later of the end of the four-month period following the final denial under the Plan or 48 hours following notification that your request for external review was denied. If initially eligible for an external review, your request will be assigned to an Independent Review Organization. The Independent Review Organization will make a determination of eligibility for external review, and provide you and the Plan with notice of its determination within 45 days of receiving the review request. Generally, only claims involving medical judgment or rescission of coverage are eligible for external review. Medical judgment for this purpose means a decision based on the Plan s medical necessity requirements, appropriateness of care, level of care, or effectiveness of a covered benefit or as otherwise contemplated by 29 C.F.R (d)(1)(ii)(A), as determined by the Independent Review Organization. If, due to your medical condition, the timeframe for completion of the standard external review process would seriously jeopardize your life or health or your ability to regain maximum function, you may request an expedited external review. Under an expedited external review, the preliminary review will be completed immediately. If your claim is determined to be initially eligible, the Claims Administrator will assign the request to an Independent Review Organization, which will complete the review as expeditiously as your medical condition requires, but in no event more than 72 hours after receiving the request. 2

3 New Hire Medical Options All employees hired on or after January 1, 2015, except those living in Hawaii, will be eligible only for the Healthy Savings or UPS Healthy Advantage options. Kaiser Health Savings is also available in Georgia and Kaiser HMO may be available in California and Hawaii. Employee Transferring from International Subsidiary If you re an employee who transfers from an international subsidiary, you will receive coverage like Newly Hired Employees as listed in table on page 10 of your Summary Plan Description as of the date of transfer or hire date in the United States. If You Don t Enroll During Initial Enrollment If you don t enroll by the deadline indicated on your enrollment worksheet or by the deadline listed in Your Benefits Resources, the online enrollment tool, your medical coverage will default to the UPS Healthy Advantage medical option. Opting Out of Medical Coverage administration. If you elect to opt out of medical coverage, your decision impacts only medical coverage. All of the other benefits offered under the plan are still available to you in accordance with the terms of the Plan. Bariatric Surgery Effective January 1, 2016, the Flexible Benefits Plan will only cover bariatric surgery on an in-network basis at a preferred facility designated by the claims administrator. Services are covered for in-network providers only. Services from out-of-network providers will not be covered. Behavioral Health and Solutions Your EAP and Work/Life Benefits ValueOptions, your employee assistance program (EAP)/mental health and substance use disorder administrator, has merged with Beacon Health Strategies to form Beacon Health Options. Only the name has changed. All benefits, provider networks, phone number and Web address remain the same. Health Savings Account (HSA) Administrator OptumHealth Bank, the administrator of the Health Savings Account, has changed its name to Optum Bank. HSA catch-up contribution for individuals age 55 and older remains an additional $1,000 per year. Flexible Spending Account (FSA) Annual Limit The maximum allowable annual contribution to an FSA for 2016 is $2,550. Clarification for 13-Month Extension at Death administration listed in the Life Events section. The additional 13-month benefits extension for covered surviving spouses and children under the Flexible Benefits Plan does not apply if your surviving spouse and children are eligible for coverage under the Retired Employees Health Care Plan. Right of Recovery For 2016, the Plan s right of recovery and subrogation rights, as prescribed in the Right of Recovery section, will be modified as follows: The Plan s reduction for attorney s fees will continue as it is currently described in the SPD subject to the following revisions: (i) the reduction provided for in the plan with respect to attorney s fees is your attorney s fees and (ii) the reduction set forth in the Plan will be conditioned on both your full cooperation with the Plan s pursuit of reimbursement and not otherwise impeding or interfering with the Plan s reimbursement right. The Plan has six (6) years from the date the Plan discovers that the covered individual has received a recovery or by the date otherwise set forth in applicable law, whichever is longer, to seek reimbursement in accordance with the terms of this Plan. Short-Term Disability Benefits administration for short-term disability (STD) benefits under the Income Protection Plan. If you return to active employment following retirement, and are receiving a retirement benefit under the UPS Retirement Plan, you are eligible to participate in the Short-Term Disability Plan; however, your STD benefits will be reduced in full by any benefits you are receiving under the UPS Retirement Plan. Health Savings Account Annual Contribution Limit The maximum allowable annual contribution to an HSA for 2016 is $3,350 for individual coverage or $6,750 for family coverage. The maximum allowable 3

4 Long-Term Disability Benefits administration for long-term disability (LTD) benefits under the Income Protection Plan. The chart in the When Your LTD Benefits End subsection applies only to Options 1 and 2. As noted previously in the SPD, the maximum duration of benefits under Option 3 is five (5) years regardless of your age when you become disabled. All Claims and Appeal Procedures For clarification purposes, you must exhaust all internal claims and appeals described in the Plan before you can file suit in federal court. For example, if you fail to file a second-level appeal, the denial on the first-level appeal will be final and binding, and you will not be able to file suit. Required Annual Notices Minimum Essential Coverage The major medical coverage provided through the plan constitutes minimum essential coverage for purposes of the individual mandate applicable to you beginning on January 1, 2015, as required by the Affordable Care Act (ACA). Dental, vision, and Health FSA coverage do NOT constitute minimum essential coverage. HIPAA Privacy Notice Your group health plan maintains a Notice of Privacy Practices that describes how the plan, and those that administer the plan, can and will use your protected health information (PHI). You received a copy of the notice when you first enrolled in the plan. The notice is also posted on UPSers.com. If you do not have access to UPSers.com, call the UPS Benefit Service Center at UPS-1508 to request a copy of the notice. Women s Health Rights The Women s Health and Cancer Rights Act requires that we notify you annually that your plan provides coverage for the following after a covered mastectomy: Reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; Treatment of physical complications of all stages of a mastectomy, including lymphedemas. Grandfathered Plan Status Unlike the UPS Healthy Advantage option, the Traditional and Healthy Savings medical plan options are a grandfathered health plan under the ACA. As permitted by the ACA, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. A grandfathered health plan may not include certain consumer protections of the ACA that apply to other plans, for example, the requirement to provide preventive health services without cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the ACA, for example, the elimination of lifetime limits on essential health benefits (as defined by the ACA). For details on which consumer protections apply to grandfathered health plans call the UPS Benefits Service Center at UPS You may also contact the Employee Benefits Security Administration, U.S. Department of Labor, at or This website has a table summarizing which protections apply to grandfathered health plans. This notice is intended to fulfill UPS s legal obligation to notify employees of material changes to the Flexible Benefits Plan. This notice formally amends the coverage available under the Plan. 2015, United Parcel Service of America, Inc. All Rights Reserved 10/

5 The Flexible Benefits Plan Plan benefits may differ for employees living in Hawaii. Check your plan insert for details. Healthy Savings UPS Healthy Advantage *** Traditional Basic Medical Provisions Deductible and out-of-pocket maximum for these two options are based on your coverage election; see page 35 of the SPD for more information. Available to UPSers hired prior to January 1, 2015 Annual deductible $1,500/single $3,000/family $3,000/single $6,000/family $1,800/single $3,600/family $3,600/single $7,200/family $300/individual $600/family $600/individual $1,200/family Annual out-of-pocket maximum $3,000/single $6,000/family $6,000/single $12,000/family $3,500/single $6,850/family $7,000/single $13,700/family $2,500/individual $5,000/family Physician Charges Office visit Inpatient surgery Outpatient surgery Hospital Facility Charges Hospital admission None None None None None None fee Inpatient services Outpatient services Emergency room 80% Urgent Care Clinic Visit 80% 85% $5,000/individual $10,000/family 85% if 65% if nonemergency Maternity Benefits Physician charges Facility charges Preventive Care Benefits** Routine physicals 100% Not covered 100% Not covered 100% Not covered OB-GYN care 100% Not covered 100% Not covered 100% Not covered Routine mammograms 100% Not covered 100% Not covered 100% Not covered Well-child care 100% Not covered 100% Not covered 100% Not covered Other Medical Benefits Diagnostic X-ray and laboratory Hospice care inpatient Hospice care outpatient Skilled nursing facility Outpatient private duty nursing Limited to 560 hours per year Home health care Limited to 4 hours per visit Chiropractic Limited to 40 visits per year Podiatrist Limited to 60 visits per year 80%;out-of-area 30 days 60%; 30 days 80%;out-of-area 30 days 60%; 30 days 85%;out-of-area 30 days 80%;out-of-area 60%; 60%; 85%; out-of-area 60%; 60%; 85%; out-of-area 65%; 30 days 65%; 65%; 80% Not covered 80% Not covered 85% Not covered

6 The Flexible Benefits Plan Plan benefits may differ for employees living in Hawaii. Check your plan insert for details. Healthy Savings UPS Healthy Advantage*** Traditional Deductible and out-of-pocket maximum for these two options are based on your coverage election; see page 35 of the SPD for more information. Other Medical Benefits (continued) Available to UPSers hired prior to January 1, 2015 Bariatric services 80% Not covered 80% Not covered 85% Not covered Rehabilitation physical, occupational and speech services Limits apply to inand out-patient services combined Ambulance Medically necessary 90 visits/year 80% 60%; 60 visits/year Behavioral Health Benefits Beacon Health Options Network Mental health (MH) and substance abuse (SA) treatment inpatient Hospital and facility admission fee Mental health (MH) and substance abuse (SA) treatment outpatient 90 visits/year 80% 60%; 60 visits/year 85%; out-ofarea 90 visits/year None None None None None None 85% 65%; 60 visits/year 85% if 65% if nonemergency *network and out-of-area medically necessary services covered by this Plan are subject to reasonable and customary limits, as determined by the Plan. **Frequency limits apply based on age and gender ***Plan covers all essential health benefits, routine services associated with an approved clinical trial and recommended preventive treatment services in accordance with the requirements of the Affordable Care Act. Generics Preferred brands** Non-preferred brands** and nonsedating antihistamines Prescription Drug Benefits (Administered by CVS Caremark) Healthy Savings or UPS Healthy Advantage*** 80% after deductible; deductible waived if preventive care med 80% after deductible; deductible waived if preventive care med 50% after deductible; deductible waived if preventive care med Traditional Available to UPSers hired prior to January 1, 2015 Retail Pharmacy Per-Script Min/Max* 80% $5/$100 $10/$200 80% $25/$150 $50/$300 50% $50/$300 $100/$600 Mail Order Per-Script Min/Max* *The per-script coinsurance minimum/maximum applies to all medical options. In the Healthy Savings or UPS Healthy Advantage options, the per-script coinsurance minimum and maximum applies only after the annual deductible has been met or if the drug is considered a preventive care medication. Until the annual deductible for this medical option has been met, you are responsible for the entire cost of the prescription. **If you purchase a brand-name drug when a generic is available, you must pay the difference in cost between the brand and generic drug, up to the non-preferred per-script maximum amount, in addition to your coinsurance amount. This difference is not included in the per-script coinsurance maximum out-of-pocket or your annual out-of-pocket maximum. ***The UPS Healthy Advantage option covers additional recommended preventive services in accordance with the Affordable Care Act (ACA). IMPORTANT INFORMATION: This summary of benefits is intended to highlight some of the key benefits of the Flexible Benefits Plan. Please refer to the appropriate section of the Summary Plan Description (SPD) for additional details that might affect coverage levels.