United HealthCare Insurance Company. Definity SM. Health Reimbursement Account. For. Rockingham County

Transcription

1 United HealthCare Insurance Company Definity SM Health Reimbursement Account For Rockingham County Group Number: Effective Date: October 1, 2009 HRA SPD

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3 Notice to Employees Definity SM Health Reimbursement Account This booklet describes the Employer-sponsored Definity SM Health Reimbursement Account (Definity SM HRA) for Rockingham County ("Plan") as of October 1, has entered into an agreement with United HealthCare Insurance Company ("UnitedHealthcare") under which UnitedHealthcare will process reimbursements and provide certain other administrative services to the Plan. References throughout this document to "we," "us," and "our" are references to the Plan Sponsor. UnitedHealthcare does not insure the benefits described in this booklet. HRA SPD

4 Table of Contents Plan Highlights...1 Who is Eligible and How to Enroll...1 Your Health Reimbursement Account...1 How Definity SM HRA Works...2 Requesting Reimbursement from Your HRA...2 When Participation Ends...3 Claims and Appeal Notice...4 HRA SPD

5 Plan Highlights About Definity SM HRA Definity SM HRA gives you choice and control over your health care decisions and expenditures by combining a high deductible medical plan design with an ancillary Health Reimbursement Account (HRA). An HRA is an account funded by your employer which helps you to cover medical plan expenses that require some element of cost-sharing, such as deductibles. Definity SM HRA is made up of three components: 1. An HRA funded by your employer and maintained by UnitedHealthcare. 2. A high deductible medical plan. 3. Health information, tools and support. Benefits available under your medical plan are described in your medical plan Certificate of Coverage (COC). Who is Eligible and How to Enroll Who is Eligible Eligibility to participate in the Definity SM Health Reimbursement Account is described in the group policy for your medical plan. Contact us if you have questions about eligibility. When You May Enroll You are enrolled in the Definity SM Health Reimbursement Account at the same time you enroll in your medical plan, as described in the medical plan COC. You will need to enroll each Plan year, even if you enrolled in Definity SM HRA the Plan year before. Your Health Reimbursement Account When you enroll in Definity SM HRA, your employer will place funds in your Health Reimbursement Account. The amount placed in your HRA will depend upon the level of coverage you enroll for. If you elect coverage for employee only, an annual amount of $500 will be placed in your HRA. If you elect coverage for employee plus one, an annual amount of $1000 will be placed in your HRA. If you elect family coverage, an annual amount of $1000 will be placed in your HRA. The funds in your HRA will be available to help you pay a portion of your out-of-pocket costs under the medical plan, including annual deductibles. If you do not use all of the funds in your HRA during the Plan year, and you re-enroll in Definity SM HRA for the following Plan year, the balance remaining in your HRA will roll over. If you choose not to re-enroll in Definity SM HRA for the following Plan year, you will continue to have access to any funds remaining in 1 HRA SPD

6 your HRA until December 31 following the end of the Plan year in which you are covered under this Plan for use with remaining prior year claims. If your employment terminates for any reason the funds in your HRA will revert back to us after your claim run-out period, unless you elect COBRA coverage as described in your medical plan COC. The HRA funds will remain available to assist you in paying your out-of-pocket costs under the medical plan while COBRA coverage is in effect. If you experience a change in status during the Plan year, and you are allowed to change your coverage level, any current balance in your HRA will remain unchanged; however, the amount placed in your HRA will change as shown below: If you decrease your coverage (e.g., from family to employee only), the amount placed in your HRA for that Plan year will not change. If you increase coverage, the additional amount placed in your HRA will increase. The increase will be the difference between what was placed in your HRA at the beginning of the Plan year and what would have been placed in your account if you had elected the additional coverage at that time. You may, while enrolled in Definity SM HRA, elect to participate in a Flexible Spending Account/Health Care Spending Account ("FSA"). If you choose to do so, you must exhaust your HRA first before you can submit claims for medical expenses to your FSA for reimbursement. How Definity SM HRA Works With Definity SM HRA, you have to meet the annual deductible (see your medical plan COC) before you are eligible for benefits under the Plan. This means that when you visit a provider, you are responsible for the costs associated with the visit until you meet your annual deductible. The money in your HRA can be used to help you satisfy some of the deductible for covered health services. If you receive services from a network provider, the provider will submit the bill to the Claims Administrator for payment. Funds from your HRA can be used to pay for covered health services until the funds in the HRA are exhausted. If you choose, you may receive services from a non-network provider; however, you will be responsible for submitting a claim to the Claims Administrator and requesting payment from the funds that remain available in your HRA. See your medical plan COC for additional information. If you deplete your HRA, you are responsible for payment of any costs incurred until you reach your annual deductible. Once your annual deductible has been met for the year, covered health services are payable at a certain percentage of eligible expenses, as shown in the benefit information portion of your medical plan COC. Requesting Reimbursement from Your HRA When you receive covered health services from a network provider, your eligible expenses will be submitted automatically to your HRA after medical claim processing has been completed. This also applies when you receive covered health services from a non-network provider who submits your claims directly to the Claims Administrator for medical claims processing. Claims for reimbursement of any medical expenses must be submitted no later than December 31 following the end of the Plan year in which you are covered under this Plan. If this information is not provided to us within this timeframe, your claim will not be eligible for reimbursement, even if there are funds available in your HRA. This time limit does not apply if you are legally incapacitated. 2 HRA SPD

7 If You Receive Covered Health Services from a Network Provider When you receive covered health services from a network provider, the funds in your HRA may be used to help you meet your annual deductible under your medical plan. Once the annual deductible is met, you are responsible for the difference between the amount of eligible expenses the medical plan pays and the total eligible expenses. Any funds left in your HRA may be used to assist you in paying this difference, up to the network out-of-pocket maximum. Filing a Claim for Covered Health Services from a Non-Network Provider If you have funds in your HRA and you receive covered health services from a non-network provider, you are responsible for filing a request for reimbursement. The request for claim reimbursement from your HRA funds may be made for claims incurred while you are considered a covered person under your medical plan. If there are funds available in your HRA, they will be used to help meet your annual deductible under your medical plan. You are responsible for the difference between the amount the non-network provider bills you and the percentage of eligible expenses paid under your medical plan. Required Information for Filing a Claim When you request reimbursement from your HRA, you must complete the Health Reimbursement Account (HRA) claim form and attach itemized documentation as described on that form. The HRA claim form is available on myuhc.com or by calling the Customer Care telephone number on your ID card. Claims and Appeals For additional information about claims and for information about appeals, see the claims and appeals sections of your medical plan COC. When Participation Ends You will cease to participate in the Plan as of the earlier of: The date on which the HRA terminates. The date your employer fails to make a required contribution under the terms of the Plan. The date you cease to be an eligible employee under the medical plan. The date your coverage would otherwise end as described in your medical plan COC. Once participation ends, any funds remaining in your HRA will revert back to us. Access to HRA funds may be available to you while you remain a covered person under the medical plan, including while COBRA continuation coverage remains in effect. Contact us for information about HRA funds during Continuation Coverage under Federal Law (COBRA). 3 HRA SPD

8 Claims and Appeal Notice This Notice is provided to you in order to describe our responsibilities under federal law for making benefit determinations and your right to appeal adverse benefit determinations. To the extent that state law provides you with more generous timelines or opportunities for appeal, those rights also apply to you. Please refer to your benefit documents for information about your rights under state law. Benefit Determinations Post-service Claims Post-service claims are those claims that are filed for payment of benefits after medical care has been received. If your post-service claim is denied, you will receive a written notice from the Claims Administrator within 30 days of receipt of the claim, as long as all needed information was provided with the claim. The Claims Administrator will notify you within this 30 day period if additional information is needed to process the claim, and may request a one time extension not longer than 15 days and pend your claim until all information is received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day time frame, and the claim is denied, the Claims Administrator will notify you of the denial within 15 days after the information is received. If you don't provide the needed information within the 45-day period, your claim will be denied. A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based, and provide the claim appeal procedures. If you have prescription drug benefits and are asked to pay the full cost of a prescription when you fill it at a retail or mail-order pharmacy, and if you believe that it should have been paid under the Plan, you may submit a claim for reimbursement in accordance with the applicable claim filing procedures. If you pay a copayment and believe that the amount of the copayment was incorrect, you also may submit a claim for reimbursement in accordance with the applicable claim filing procedures. When you have filed a claim, your claim will be treated under the same procedures for post-service group health plan claims as described in this section. Pre-service Requests for Benefits Pre-service requests for benefits are those requests that require notification or approval prior to receiving medical care. If you have a pre-service request for benefits, and it was submitted properly with all needed information, you will receive written notice of the decision from the Claims Administrator within 15 days of receipt of the request. If you filed a pre-service request for benefits improperly, the Claims Administrator will notify you of the improper filing and how to correct it within 5 days after the pre-service request for benefits was received. If additional information is needed to process the pre-service request, the Claims Administrator will notify you of the information needed within 15 days after it was received, and may request a one time extension not longer than 15 days and pend your request until all information is received. Once notified of the extension you then have 45 days to provide this information. If all of the needed information is received within the 45-day time frame, we will notify you of the determination within 15 days after the information is received. If you don't provide the needed information within the 45-day period, your request for benefits will be denied. A denial notice will explain the reason for denial, refer to the part of the Plan on which the denial is based, and provide the appeal procedures. If you have prescription drug benefits and a retail or mail order pharmacy fails to fill a prescription that you have presented, you may file a pre-service health request for benefits in accordance with the applicable claim filing procedure. When you have filed a request for benefits, your request will be treated under the same procedures for pre-service group health plan requests for benefits as described in this section. 4 HRA SPD

9 Urgent Requests for Benefits that Require Immediate Attention Urgent requests for benefits are those that require notification or a benefit determination prior to receiving medical care, where a delay in treatment could seriously jeopardize your life or health, or the ability to regain maximum function or, in the opinion of a Physician with knowledge of your medical condition, could cause severe pain. In these situations: You will receive notice of the benefit determination in writing or electronically within 72 hours after the Claims Administrator receives all necessary information, taking into account the seriousness of your condition. Notice of denial may be oral with a written or electronic confirmation to follow within 3 days. If you filed an urgent request for benefits improperly, the Claims Administrator will notify you of the improper filing and how to correct it within 24 hours after the urgent request was received. If additional information is needed to process the request, the Claims Administrator will notify you of the information needed within 24 hours after the request was received. You then have 48 hours to provide the requested information. You will be notified of a benefit determination no later than 48 hours after: The Claims Administrator's receipt of the requested information; or The end of the 48-hour period within which you were to provide the additional information, if the information is not received within that time. A denial notice will explain the reason for denial, refer to the part of the Plan on which the denial is based, and provide the appeal procedures. Concurrent Care Claims If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an urgent request for benefits as defined above, your request will be decided within 24 hours, provided your request is made at least 24 hours prior to the end of the approved treatment. The Claims Administrator will make a determination on your request for the extended treatment within 24 hours from receipt of your request. If your request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the request will be treated as an urgent request for benefits and decided according to the timeframes described above. If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and you request to extend treatment in a non-urgent circumstance, your request will be considered a new request and decided according to post-service or pre-service timeframes, whichever applies. Questions or Concerns about Benefit Determinations If you have a question or concern about a benefit determination, you may informally contact the Claims Administrator's Customer Care department before requesting a formal appeal. If the Customer Care representative cannot resolve the issue to your satisfaction over the phone, you may submit your question in writing. However, if you are not satisfied with a benefit determination as described above, you may appeal it as described below, without first informally contacting a Customer Care representative. If you first informally contact Customer Care and later wish to request a formal appeal in writing, you should again contact Customer Care and request an appeal. If you request a formal appeal, a Customer Care representative will provide you with the appropriate address. If you are appealing an urgent claim denial, please refer to Urgent Appeals that Require Immediate Action below and contact Customer Care immediately. 5 HRA SPD

10 How to Appeal a Claim Decision If you disagree with a pre-service request for benefits determination or post-service claim determination after following the above steps, you can contact the Claims Administrator in writing to formally request an appeal. Your request should include: The patient's name and the identification number from the ID card. The date(s) of medical service(s). The provider's name. The reason you believe the claim should be paid. Any documentation or other written information to support your request for claim payment. Your first appeal request must be submitted to the Claims Administrator within 180 days after you receive the claim denial. Appeal Process A qualified individual who was not involved in the decision being appealed will be appointed to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a health care professional with appropriate expertise in the field, who was not involved in the prior determination. The Claims Administrator (first level appeals) and the Plan Administrator (second level appeals) may consult with, or seek the participation of, medical experts as part of the appeal resolution process. You consent to this referral and the sharing of pertinent medical claim information. Upon request and free of charge, you have the right to reasonable access to (including copies of) all documents, records, and other information relevant to your claim for Benefits. Appeals Determinations Pre-service Requests for Benefits and Post-service Claim Appeals You will be provided written or electronic notification of the decision on your appeal as follows: For appeals of pre-service requests for benefits as identified above, the first level appeal will be conducted and you will be notified of the decision within 15 days from receipt of a request for appeal of a denied request for benefits. The second level appeal will be conducted and you will be notified by us of the decision within 15 days from receipt of a request for review of the first level appeal decision. For appeals of post-service claims as identified above, the first level appeal will be conducted and you will be notified by the Claims Administrator of the decision within 30 days from receipt of a request for appeal of a denied claim. The second level appeal will be conducted and you will be notified by us of the decision within 30 days from receipt of a request for review of the first level appeal decision. For procedures associated with urgent requests for Benefits, see Urgent Appeals That Require Immediate Action below. If you are not satisfied with the first level appeal decision of the Claims Administrator, you have the right to request a second level appeal from us as the Plan Administrator. Your second level appeal request must be submitted to us within 60 days from receipt of the first level appeal decision. The Plan Administrator has the exclusive right to interpret and administer the Plan, and these decisions are conclusive and binding. 6 HRA SPD

11 Please note that our decision is based only on whether or not benefits are available under the policy for the proposed treatment or procedure. We don't determine whether the pending health service is necessary or appropriate. That decision is between you and your physician. Urgent Appeals that Require Immediate Action Your appeal may require immediate action if a delay in treatment could significantly increase the risk to your health, or the ability to regain maximum function, or cause severe pain. In these urgent situations: The appeal does not need to be submitted in writing. You or your physician should call the Claims Administrator as soon as possible. The Claims Administrator will provide you with a written or electronic determination within 72 hours following receipt by the Claims Administrator of your request for review of the determination, taking into account the seriousness of your condition. For urgent requests for benefits appeals, we have delegated to the Claims Administrator the exclusive right to interpret and administer the provisions of the Plan. The Claims Administrator's decisions are conclusive and binding. 7 HRA SPD

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14 /04/2009