Schedule of Benefits for UAW-General Motors Retirees

Transcription

1 Schedule of Benefits for UAW-General Motors Retirees Addendum to the Summary Plan Description Published: January 2010 The Committee of the UAW Retiree Medical Benefits Trust is pleased to provide you with this Schedule of Benefits as a supplement to your Summary Plan Description booklet. This Schedule of Benefits contains information about the preventive services that are covered under your medical plan and cost-sharing obligations applicable to your health care benefits effective January 1, You should refer to this Schedule of Benefits along with your Summary Plan Description. For information about... See page... Cost-Sharing Items for Preventive Care Services/Screenings 3 Hearing Aid Coverage 4 Contact Information 6 This Schedule of Benefits is incorporated into and made part of the UAW Retiree Medical Benefits Trust Summary Plan Description. If you have questions that are not answered in these materials, contact Retiree Health Care Connect ( ) or your health care Carrier. General Motors Schedule 1

2 Cost-Sharing Items for 2010 The following table outlines the major provisions of the Medical Plans offered by the UAW Retiree Medical Benefits Trust effective January 1, The amounts may be adjusted annually or at other times as determined by the Committee. Note: Some plan benefits will be different depending on whether you are a General or Protected Retiree or Surviving Spouse. A Protected Retiree or Surviving Spouse is one who is receiving an annual pension benefit income of $8,000 or less and a monthly pension benefit rate of $33.33 or less per month per year of credited service. A General Retiree or Surviving Spouse is one who is receiving an annual pension benefit income of more than $8,000 or a monthly pension benefit rate over $33.33 per month per year of credited service. Most Retirees and Surviving Spouses will be General Retirees. If you have any question about your status, contact Retiree Health Care Connect ( ). Cost-Sharing Items Monthly Contribution for All Plans Protected Retiree General Retiree Single $15 $15 Family $15 $30 Deductible for PPO & TCN Co-Insurance Maximum Out-of-Pocket Expenses for PPO & TCN Office Visit Co-payment Emergency Room Co-payment Retail Prescription Drug Co-payment Mail Order Prescription Drug Co-payment In-Network Single $170 Family $340 Out-of-Network Single $170 Family $340 In-Network 10% Out-of-Network 30% In-Network Single $285 Family $570 Out-of-Network Single $570 Family $1, % Traditional Care Network (TCN) $10 HMO (may vary by plan) PPO, TCN & HMO $100 (waived if admitted) Medicare Advantage $50 (may vary by plan) Generic $10 Brand $25 Generic $20 Brand $50 2 General Motors Schedule

3 Preventive Care Services/Screenings The specific limitations may be adjusted from time to time and are in accordance with guidelines set by accepted national standards. The current coverage is reflected in the following table. Service PAP Smear Application and Limitations 1 per year Proctoscopic Exams Without Biopsy 1 every 3 years, for participants age 40 and older Mammogram Prostate-Specific Antigen (PSA) Fecal Occult Blood or Fecal Immunochemical Test Flexible Sigmoidoscopy, Barium Enema, Colonoscopy 1 per year, for participants age 40 and older 1 per year, for participants age 40 and older 1 per year, for participants age 50 and older For participants age 50 or older: 1 Flexible Sigmoidoscopy or 1 Barium Enema every 5 years OR 1 Colonoscopy every 10 years Total Serum Cholesterol with LDL Test 1 every 5 years, for participants age 20 and older Hepatitis C Screening Well Baby Care Immunizations and Vaccinations For participants at risk, or who have signs or symptoms that may indicate a Hepatitis C infection 6 visits to physician during first 2 years of life Coverage is based on the recommendations and approvals of the Advisory Committee on Immunization Practices, including appropriate dosages, ages and frequency of administration (consult your Carrier for current provisions) General Motors Schedule 3

4 Hearing Aid Coverage How Hearing Aid Coverage Works Benefits for hearing aids and related services are provided when services are obtained from Participating Providers. For services to be covered, an ear specialist (otologist or otolaryngologist) must first examine you. This examination is to determine if your hearing problem is caused by a condition that may be corrected by use of a hearing aid. Hearing Aid Covered Charges If it is determined that your hearing problem may be corrected by use of a hearing aid, benefits can be provided. Payment will be made up to the Allowed Amount for the services listed below. Benefits are payable once during any period of three consecutive calendar years when obtained from a Participating Provider. Audiometric examination; Hearing aid evaluation test (subject to maximum benefit); and One standard hearing aid and ear mold (acquisition cost and dispensing fee). However, only the specific hearing aid prescribed as a result of the hearing aid evaluation test will be covered. Coverage for a non-standard hearing aid is limited to the Allowed Amount for one standard hearing aid; Necessary fitting and adjustment of the hearing aid; Binaural hearing aids (one aid for each ear) for Dependent Children 19 years of age and under, but only if there is hearing loss in both ears. Hearing Aid Expense Exclusions Hearing aid services not covered under the Trust include: Services and equipment received from Non-Participating Providers; Medical or surgical treatment; Drugs or other medications; Audiometric examinations and hearing aid evaluation tests performed and hearing aids ordered before coverage becomes effective or after coverage ends, unless a hearing aid is prescribed before coverage ends and is delivered and fitted within 60 days; Replacement of lost or broken hearing aids; Replacement of parts for, and repairs of, hearing aids; Deluxe hearing aids (including but not limited to digital, programmable and eyeglass-type hearing aids) to the extent the charge for such hearing aids is more than the standard covered hearing aid expense for one basic hearing aid; 4 General Motors Schedule

5 The cost for more than one audiometric exam, hearing aid evaluation test or hearing aid during any three consecutive calendar year periods; Services provided under Workers Compensation or other government plans; Services or supplies provided under federal or state programs or supplied by a government agency; Hearing aids that do not meet Food and Drug Administration (FDA) and Federal Trade Commission (FTC) requirements; and Binaural Hearing Aids except for Dependent Children 19 years of age and younger. General Motors Schedule 5

6 Contact Information Plans notated with an asterisk (*) may not be available in all geographic areas. The dates plans become available in specific regions or areas will be communicated as necessary. Contact Retiree Health Care Connect for information. Call Centers Retiree Health Care Connect (Eligibility Benefits Center) Pension Administrator Medicare CMS/Centers for Medicare & Medicaid Services GM Benefits and Services Center Medicare Service Center: 800-MEDICARE ( ) Medicare Service Center TTY: Health Plan Carriers Claim Inquiries Appeals Advantage HMO Indiana* Blue Care Network HMO* Blue Advantage HMO Illinois* Blue Care HMO Kansas City* Blue Cross Blue Shield Traditional Care Network (TCN) Advantage HMO Indiana 9045 River Road, Suite 200 Indianapolis, IN Blue Care Network or BCN Advantage Member Reimbursement P.O. Box Grand Rapids, MI Blue Advantage HMO P.O. Box Chicago, IL Blue Cross Blue Shield of Kansas City 2301 Main Street P.O. Box Kansas City, MO UAW Auto Retiree Service Center P.O. Box Detroit, MI Advantage HMO Indiana 9045 River Road, Suite 200 Indianapolis, IN Blue Care Network or BCN Advantage Attn: Appeals and Grievances Mail Code 248 P.O. Box 284 Southfield, MI Blue Advantage HMO P.O. Box Chicago, IL Blue Cross Blue Shield of Kansas City 2301 Main Street P.O. Box Kansas City, MO UAW Auto Retiree Appeals Unit Mail Code 2004 Blue Cross Blue Shield of Michigan 600 Lafayette East Detroit, MI General Motors Schedule

7 Health Plan Carriers Claim Inquiries Appeals Green Shield* (Canada) Health Alliance Plan (HAP) HMO* HMO: Medicare Advantage: Health Partners HMO Minnesota* (non-medicare Retirees) (Medicare Retirees/Freedom Plan Participants) Health Plus* Home Medical Equipment (HME formerly Northwood) (Durable Medical Equipment Benefit Manager) Humana HMO* HMO California* HMO North West* HAP ATTN: Claims Department 2850 W. Grand Blvd. Detroit, MI Health Partners Medical Claims P.O. Box 1289 Minneapolis, MN Health Plus Claims 2050 S. Linden Road Flint, MI HME Claims P.O. Box 3078 Centerline, MI Humana Claims P.O. Box Lexington, KY Northern California: Attn: California Claims Administration Department P.O. Box Oakland, CA Southern California: Claims Administration Department P.O. Box 7004 Downey, CA Kaiser Foundation Health Plan of the NW Claims Administration 500 NE Multnomah St. Suite 100 Portland, OR HAP Vice President Client Services 2850 W. Grand Blvd. Detroit, MI Health Partners Member Services P.O. Box 1309 Minneapolis, MN Health Plus Appeals 2050 S. Linden Road Flint, MI HME National Network Auto National Appeals Unit P.O. Box 3078 Centerline, MI Humana Grievance & Appeals P.O. Box Lexington, KY Submit orally or in writing to local member services department at plan facility. Expedited Review Unit: Fax Mon-Sat, 8:30-5 Kaiser Foundation Health Plan, Inc. Expedited Review Unit P.O. Box Oakland, CA Kaiser Foundation Health Plan of the NW (Grievance/Appeals) 500 NE Multnomah St. Suite 100 Portland, OR General Motors Schedule 7

8 Health Plan Carriers Claim Inquiries Appeals HMO Georgia* HMO Ohio* HMO Colorado* Medco Health Solutions (Pharmacy Benefit Manager) Mercy Care HMO Wisconsin* Univera* Value Options (Behavioral Health Benefits Manager) Claims P.O. Box Atlanta, GA Claims Department P.O. Box 5316 Cleveland, OH P.O. Box Denver, CO Medco Health Solutions 8111 Royal Ridge Parkway Irving, TX Mercy Care HMO Claims P.O. Box 2770 Janesville, WI Univera Claims P.O. Box Rochester, NY Value Options Alpha Drive, Suite #150 Wixom, MI Appeals 3495 Piedmont Road NE Atlanta, GA Appeals Unit Kaiser Foundation Health Plan of Ohio P.O. Box Cleveland, OH Member Services 2500 S. Havana St. Aurora, CO Medco Health Solutions Attn: Appeals Unit 8111 Royal Ridge Parkway Irving, TX Mercy Care HMO Appeals P.O. Box 2770 Janesville, WI Univera Appeals P.O. Box Rochester, NY Value Options Alpha Drive, Suite #150 Wixom, MI This Schedule of Benefits is meant to be an easy-to-understand description of your program of health care benefits, but it does not replace the official Plan Document. If there is any conflict between the wording of the Plan Document and this Schedule of Benefits, the Plan Document governs. 8 General Motors Schedule _03