Open Enrollment Guide Seminarian Health Plans

Transcription

1 Open Enrollment Guide Seminarian Health Plans Plan Year August 1, July 31, 2016 The Episcopal Church Medical Trust Our Health, Our Members, Our Church

2 Introduction The Episcopal Church Medical Trust is pleased to begin a relationship with you now, at an early stage of your career with the Church. We care about your health and are dedicated to providing comprehensive and affordable healthcare benefits to you and your family. We hope that this guide will help you: Learn about caring for your healthcare needs in the coming plan year Understand your plan design and how it works Learn more about the importance of wellness As a seminarian, you have unique healthcare needs. Your family may be living in another state, you might be planning to travel during summers, or your family may be growing and therefore anticipating greater medical needs. That s why the Medical Trust provides you with a specially designed benefit plan. Your Role In The Value Of Your Healthcare You play a very important part in realizing the value of your healthcare. While the Medical Trust, insurance companies, and the government can all play a role in managing costs and ensuring that people receive cost-effective and comprehensive care, it s also within your power to impact your own individual costs and outcomes. What can you do? Whether or not you choose the seminarian plan offered by the Episcopal Church Medical Trust, consider taking the following steps to becoming a better healthcare consumer and ensuring your long-term health and wellness: Partner with your doctor. One very good way to make sure you re getting excellent healthcare is to have a doctor with whom you can build a long-term relationship. When you build that relationship, your doctor knows about your medical background and understands what s important to you. Having a physician you know and trust helps you to feel comfortable talking about your health concerns. And getting your basic care, such as routine exams, preventive care, and treatment for illnesses or injuries, is a smoother and easier process. Your doctor also knows when it s best to refer you to a specialist. Explore your treatment options. Some people believe that being a good patient means simply doing whatever the doctor says to do; to just follow the first treatment he or she suggests. But, actually, staying quiet is not such a good idea. Talking with your doctor about all your treatment options may help you find one that works better for you. The path to understanding your options starts with asking your doctor questions about your condition. Then fully discuss the available treatments and speak up about any concerns you have about the various options. Learn more about your condition. If you use the Internet to find health information, start by searching specialized sites connected with certain diseases. For example, if you re interested in learning about heart disease, visit the American Heart Association website at for asthma and allergies, visit the 1

3 American Academy of Allergy, Asthma and Immunology website at or for cancer, visit the American Cancer Society website at You can also find valuable information on the Anthem website at As with any information you research on the Internet, know where the information is coming from and be wary of any site that wants to sell you something. Get the most value from your prescription drug benefit. While many factors that drive prescription drug increases are out of your control, there are steps you can take to save money. For an occasional minor ailment such as joint pain, heartburn, or allergies, ask your doctor if you can try an over-the-counter treatment first. Request generic or preferred branded drugs when possible. Use a participating retail pharmacy, or better yet, use the mail-order program to reduce your costs even more. Stay well. Your health is in your hands. As simple as it may seem, if you want to stay healthy and live a longer, healthier life, it can help to know your health risks and how to manage them. Get regular checkups, monitor your blood pressure, tell your doctor about all of the medication you re taking, and get the recommended screenings for your age and gender. Knowing your numbers such as blood pressure, cholesterol, and BMI (body mass index) are important to understanding where you are in the wellness continuum. Also consider exercising regularly and quitting smoking. While taking good care of your health today, you will be setting the stage for better health later in life and in retirement. By actively taking a role in managing your own health, you can achieve personal wellness and positively influence those around you. About Your Plan The Episcopal Church Medical Trust offers seminarians the Anthem Blue Cross and Blue Shield (BCBS) PPO 75/50 Plan. This plan includes prescription drug coverage, along with the flexibility to cover just yourself, or your spouse and children if you have a family. The plan provides national coverage, which ensures that you are covered regardless of where your school is or where your travels take you. Even if your family members live in a different state, they are covered as long as they are eligible and you enroll them. Anthem BCBS PPO 75/50 Plan Highlights The Anthem BCBS PPO 75/50 Plan is a preferred provider organization (PPO) design. This means you can use any provider you want, but you will save money if you use the plan s network of preferred providers the participating doctors, hospitals, and other providers who have agreed to accept lower fees for their services. You can receive services from any provider and you don t need to choose a primary care physician (PCP) or coordinate your care through one. 2

4 In a sense, the PPO gives you the most flexibility to visit the providers you choose in or out of the plan s network. However, the plan pays greater benefits if you receive care from a preferred provider or facility. If you choose an out-of-network provider, it is important to note that you may be responsible for submitting your own claims. In-network preventive care is covered at 100% The plan also places a limit on your annual out-of-pocket expenses. There is a lower in-network annual deductible that applies when you use a network provider, and a higher out-of-network deductible that applies which you do not use a network provider. Feature/Benefit Annual Deductible In-Network Out-of-Network Annual Out-of-Pocket Maximum Anthem BCBS PPO 75/50 Plan $900 Individual/$1,800 Family $1,800 Individual/$3,600 Family In-Network $4,100 Individual/$8,200 Family Out-of-Network $8,200 Individual/$16,400 Family Emergency Room Services Covered at 100% after $100 copay (copay waived if admitted as an inpatient) Physician Office Visits Covered at 100% after $35 copay (PCP) or $45 copay (specialist) Preventive Services Covered at 100% Diagnostic X-Ray and Lab Services Covered at 75% Inpatient Hospital Services Covered at 75% after $100 per day copay (copay not to exceed $600) Outpatient Hospital Services Covered at 75% Outpatient Mental Health Covered at 100% after $20 copay (benefits through Cigna Behavioral Health) (pre-authorization required) Inpatient Mental Health (pre-authorization required) All Other Covered Services In-Network Out-of-Network Covered at 100% after $100 per day copay, $600 maximum copay per admission (benefits through Cigna Behavioral Health) Covered at 75% Covered at 50% For More Plan Details Please note that the information in this brochure provides a basic description of the plan. For complete details, including the Summary of Benefits and Coverage, please see the Anthem BCBS PPO 75/50 Plan handbook at Keep in mind that benefits under this plan are subject to change each plan year. 3

5 Express Scripts Prescription Drugs Feature Retail Prescription Drugs Home Delivery Prescription Drugs Annual Deductible $50 per individual None Tier 1: Generic You pay up to $10 You pay up to $25 Tier 2: Formulary Brand-Name You pay up to $35 You pay up to $90 Tier 3: Non-Formulary Brand-Name and You pay up to $60 You pay up to $150 Non-Sedating Antihistamines Dispensing Limits Per Copayment Generic Substitution Requirement Up to a 30-day supply Up to a 90-day supply Generic medications and their brand-name counterparts have the same active ingredients and are manufactured according to the same strict federal regulations. Generic drugs may differ in color, size, or shape, but the U.S. Food and Drug Administration (FDA) requires that the active ingredients have the same strength, purity, and quality as their brand-name counterparts. For this reason, the Plan will cover the cost of the generic equivalent if you purchase a brand-name medication when there is a generic available. You will be charged the generic copayment and the cost difference between the brand-name and the generic medication. If you have questions or concerns about generic medications, speak to your physician or your pharmacist, and he or she will be able to help you. Retail Refill Limit The Prescription Drug Program includes a Retail Refill Limit policy. The retail refill limit requires that you use home delivery if you are prescribed a maintenance medication, rather than refilling multiple prescriptions for the same drug at a retail pharmacy. If you or a covered dependent receives a prescription for a maintenance medication and you do not use home delivery, your prescriptions may not be covered. In some circumstances, you may not be required to use home delivery. For example, there are several categories of medications that are uniquely appropriate for multiple refills at your local pharmacy (and are therefore exempt from the mandatory mail-order provision, as outlined above). See the Summary of Benefits and Coverage for more information. The benefit summaries on the preceding charts are provided for informational purposes, are not all-inclusive and do not constitute an agreement. Additional limitations and explanations, including specific benefit maximums are available in the Plan Document Handbooks. In the event of a conflict between this document and the official plan documents, the official plan documents will govern. The Episcopal Church Medical Trust retains the right to amend, terminate or modify the terms of the plan at any time, for any reason and unless required by law, without notice. 4

6 Dental Benefits The dental plans available to you are administered by Cigna. You may choose from the three dental Plans described below during open enrollment. Please refer to the chart to compare the coverage levels available in each Plan. All three plans allow you to see the provider of your choice and provide three cleanings per calendar year with no copay. You can receive care from providers participating in the network, or you can choose to use out-of-network providers. However, you will be reimbursed at a higher level if you use providers who participate in the Cigna network. You can access the dental provider directory at or by calling (800) Feature Out-of-Network Annual Deductible Annual Benefit Maximum Preventive & Diagnostic Services (e.g., oral exams, cleanings, X- rays, emergency care to relieve pain) Basic Restorative Services Major Restorative Services Dental & Orthodontia PPO Basic Dental PPO Preventive Dental PPO $25 Individual $50 Individual No deductible $75 Family $150 Family $2,000 Individual $2,000 Individual $1,500 Individual You pay 0% (not subject to the annual deductible or manual benefit maximum) You pay 15% (and all amounts above the annual benefit maximum) Includes fillings, root canal therapy, periodontal scaling and root planing, denture adjustments and repairs, extractions, and anesthetics. You pay 15% (and all amounts above the annual benefit maximum) Includes crowns, dentures, oral surgery, osseous surgery, dental implants, night guards and bridges. Orthodontia You pay 50% ($1,500 individual lifetime maximum) You pay 0% (not subject to the annual deductible or annual benefit maximum) You pay 15% (and all amounts above the annual benefit maximum) Includes fillings, root canal therapy, periodontal scaling and root planing, denture adjustments and repairs, extractions, and anesthetics. You pay 50% (and all amounts above the annual benefit maximum) Includes crowns, dentures, oral surgery, osseous surgery, dental implants, night guards and bridges. You pay 0% (not subject to the annual benefit maximum) (includes sealants to age 14) You pay 20% (and all amounts above the annual benefit maximum) Includes only fillings, denture adjustments and denture repairs. You pay 99% (and all amounts above the annual benefit maximum) Includes crowns, dentures, oral surgery, osseous surgery, bridges, and root canal therapy. Not covered You pay 99% (and all amounts above the annual benefit maximum) This chart contains only a partial, general description of the Plans; refer to the Dental Plan Handbook for details. 5

7 Additional Benefits Vision If you are enrolled in a medical plan through the Medical Trust, you will receive vision benefits from EyeMed Vision Care. Through EyeMed, you can receive care from providers participating in the network, or you can choose to use out-of-network providers. However, you will be reimbursed at a higher level if you use providers who participate in the EyeMed network. If you seek care from a network provider, there is no copayment for an eye examination. You pay $10 for single, bifocal, or trifocal lenses, and there is a $130 allowance for frames or contact lenses. These services are covered once per calendar year. For more information about EyeMed, and to see a list of EyeMed providers, please visit the pre-enrollment website at or call EyeMed tollfree at (866) Mental Health Benefits If you are enrolled in the medical plan offered to seminarians through the Medical Trust, your inpatient and outpatient mental health and substance abuse benefits will be administered by Cigna Behavioral Health (CBH). Through our partnership with CBH, members will have access to an integrated behavioral health program that includes mental health, substance abuse, and employee assistance benefits. CBH will provide clinical support customer services and behavioral health claims processing for our plan members. Employee Assistance Program Life can be challenging and stressful. Everyone needs support from time to time. The Employee Assistance Program (EAP), which is administered by Cigna Behavioral Health (CBH), is available to all seminarians enrolled in the medical plan through the Medical Trust and covers a vast array of family and personal services. The program is designed to assist our members with information, educational materials, resources, referrals and ongoing support. EAP services are available 24 hours a day, 7 days a week through the CBH website or by phone. All services are free and confidential. Equipped with many tools, the EAP staff members are trained to provide you with a range of services including: help finding daycare for your children, support for managing stress, information on adoption, assistance in researching nursing homes, and much more. To access the Cigna Employee Assistance Program (EAP), visit or call (866) , 24 hours a day, 7 days a week. 6

8 Health Advocate The Health Advocate program is available to all seminarians enrolled in the medical plan offered through the Medical Trust. Health Advocate helps members navigate and facilitate medical and administrative issues in the healthcare system. Services through this program are provided by personal health advocates, typically registered nurses, backed by a team of medical directors and administrative experts who will help with arranging appointments, sorting out claims issues, scheduling specialized tests, assisting in transferring medical records, arranging for home care equipment after a hospitalization, and much more. For more information about Health Advocate or to access their services, call (866) Enrollment Eligibility You may be eligible to enroll in health benefits if you are a seminarian who is a full-time student enrolled at a participating seminary of the Association of Episcopal Seminaries. You can enroll the following dependents in your plan: A spouse A domestic partner A child who is 30 years of age or younger on December 31 of the current year* A disabled child, 30 years of age or older on December 31 of the current year, provided the disability began before the age of 25* *The Dependent must be enrolled under the Subscriber s Plan. Enrolling In The Plan If you want to be covered by the available plan for the current semester, you need to enroll within 30 days of your seminary s published registration deadline for that semester. If you do not enroll by that deadline, you can enroll in any subsequent semester and your coverage will start with that semester. As an enrolled member, you will remain enrolled in that plan year-round for the duration of your time in seminary, until you are no longer eligible (for example, because you graduate) or you elect to terminate your coverage. Changing Your Coverage At any time during the year, you can change your coverage level if you experience a significant life event. Examples of a significant life event include getting married or divorced, having or adopting a child, or experiencing a significant change in your spouse s health coverage. See your administrator for a full list of eligible life events. 7

9 Please note: The medical plan in our seminarian health program has a benefit year of August 1 through July 31. The benefit year is the same regardless of your enrollment date, which may vary as a result of your school s calendar year and/or registration timing. The benefit period for the dental plans and the vision benefit is based on the calendar year of January 1 through December 31. Monthly Rates Monthly rates are based on your age at the time you enroll and your level of coverage. There are four coverage levels: You only You plus your spouse You plus your children You plus your spouse and children (family coverage) Questions and Answers During the school year, my spouse and I live in different states. Will the plan cover both of us? Yes. The plan provides nationwide coverage. The plan allows you to use any doctors you choose in each of the states you live in, but you will pay less if you use doctors who are in the network. (Refer to the last page of this brochure for information on finding out which providers are in the network.) I plan to travel outside of the country next summer. If I enroll in a plan, will I still be covered? Yes. Anthem provides benefits for care received outside of the U.S. I would like to enroll in the medical plan, but want to make sure my current doctor is available on an in-network basis. How can I check? You can visit the website of the medical plan. Refer to the last page of this brochure for contact information. Where can I find out more details about the plan? If you need more plan details, you can download the plan handbook from the Episcopal Church Medical Trust website at Resource Contact Information 8

10 Member Services Find a doctor Cigna Behavioral Health & Employee Assistance Program (EAP) Cigna Dental Prescription Drug Program List of participating pharmacies Home delivery Information on covered drugs Vision Program Locate participating providers Benefits information Health Advocate Administrative Issues Benefits Appeals Plan brochures Questions Anthem Blue Cross and Blue Shield (844) (Monday-Friday, 8:30 am 8:00 pm ET) (866) (24 hours a day, 7 days a week) (800) Monday through Friday, 8:00 a.m. - 6:00 p.m. Express Scripts (access for enrolled members) (800) (24 hours a day, 7 days a week) EyeMed Vision Care (Monday-Saturday, 8:00 am 11:00 pm ET; Sunday, 11:00 am 8 pm ET) (866) (24 hours a day/7 days a week) The Episcopal Church Medical Trust (800) (Monday Friday, except holidays, 8:30 am 8:00 pm ET) The Plan(s) described in this handbook are sponsored and administered by the Church Pension Group Services Corporation ( CPGSC ), also known as the Episcopal Church Medical Trust (the Medical Trust ). The Plans that are selffunded are funded by the Episcopal Church Clergy and Employees Benefit Trust ( ECCEBT ), a voluntary employees beneficiary association within the meaning of section 501(c)(9) of the Internal Revenue Code. This handbook contains only a partial description of the Plans intended for informational purposes only. It should not be viewed as a contract, an offer of coverage, or investment, tax, medical, or other advice. In the event of a conflict between this handbook and the official Plan documents (summary of benefits and coverage, Summary Plan Description, booklet, booklet-certificate), the official Plan documents will govern. The Church Pension Fund and its affiliates, including but not limited to the Medical Trust, CPGSC and ECCEBT (collectively, CPG ), retain the right to amend, terminate, or modify the terms of the Plans, as well as any post-retirement health subsidy, at any time, for any reason and unless required by law, without notice. The Plans are church plans within the meaning of section 3(33) of the Employee Retirement Income Security Act and section 414(e) of the Internal Revenue Code. Not all Plans are available in all areas of the United States, and not all Plans are available on both a self-funded and fully insured basis. The Plans do not cover all health care expenses, and Members should read the official Plan documents carefully to determine which benefits are covered, as well as any applicable exclusions, limitations, and procedures. CPG does not provide any health care services and therefore cannot guarantee any results or outcomes. Health care providers and vendors are independent contractors in private practice and are neither employees nor agents of CPG. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. 9