Medical Coverage - SummaCare Medicare Supplement Plan (dependents 65 +)

Transcription

1 Medical Coverage - SummaCare Medicare Supplement Plan (dependents 65 +) The University is continuing medical coverage with SummaCare Medicare Supplement for retiree dependents over age 65. This plan will continue to offer the Medicare maintenance of benefits model. A chart detailing the coverage is enclosed. For coverage specific questions, please contact SummaCare at (800) or refer to the plan document and summary available at Medicare Enrollment Information Medicare is the federal health insurance program for people age 65 and over (and certain disabled individuals under age 65). If you are eligible for Social Security benefits (including disability benefits), you may apply for Medicare. There are three basic parts to Medicare: hospital insurance, medical insurance and prescription drug insurance. Medicare Part A is hospital insurance that covers hospitalization, hospice care, some skilled nursing and home health care. Part A also helps pay for durable medical equipment, such as a hospital bed or wheelchair. Medicare Part B is medical insurance that covers some of the costs of necessary medical services and equipment; including doctors fees, physical, occupational, and speech therapies, durable medical equipment, x-rays and lab tests. Parts A and B together are generally referred to as "Original Medicare". Medicare Part C, also called Medicare Advantage, combines Part A and Part B options into an HMO plan administered by private insurance companies. In most cases, Part C is a lower-cost alternative to Original Medicare. Providers usually offer extra benefits, including prescription drug coverage (Part D). Medicare Part D is prescription drug insurance. A variety of plans are available to suit the consumer's needs, preferences and budgets. Consumers pay a monthly premium and low copayments for each prescription filled. A deductible may also apply. Medicare is administered by individual states and the federal government, not by The University of Akron. For general Medicare information, contact MEDICARE ( ) 24 hours a day, 7 days a week for assistance. Medicare's Annual Open Enrollment is from October 15 - December 7. Page 1 of 5

2 Maintenance of Benefits with Medicare Maintenance of benefits with Medicare affects plan participants who are age 65 and above. Under maintenance of benefits with Medicare, (also called a Medicare Carve Out ) the secondary plan (SummaCare) calculates the benefit that would be paid as though it were the primary plan, then subtracts the payment of the primary plan (Medicare Part A or B) and pays the difference, if any. No payment will be made by SummaCare if the SummaCare benefit is equal to or less than the Medicare benefit. Medicare typically reimburses 80% of its allowed charges. If a plan participant is age 65 or greater and does not have Medicare A and/or B, the plan will continue to pay secondary as if you have Medicare Part A & Part B. You (or your other insurance in accordance with their rules) will pay the portion Medicare would have paid. It is not recommended to continue your coverage with this plan if you do not have Medicare A&B. Following are examples of how this plan works (after deductible): Your eligible dependent has a surgery costing $1,000 and Medicare allows $1,000 as primary and pays 80%, or $800 of the cost. If the University Plan would normally pay 80% or $800 for the same service, no further benefit is paid for this claim and the dependent would be responsible for the remaining 20%, or $200. Your eligible dependent has a surgery costing $1,000 and Medicare allows $700 as primary and pays 80%, or $560 of the cost. If the University Plan allows $1000 and would normally pay 80% or $800 for the same service, the University Plan would pay an additional $240 towards the claim. The dependent would be responsible $0. Prescription Drug coverage - EnvisionRx Options and Orchard Pharmaceutical The University is continuing prescription drug coverage with EnvisionRx Options for prescription drugs filled at retail locations (Walgreens, CVS, Giant Eagle, Acme, etc.). A chart detailing the coverage is enclosed. For questions regarding retail pharmacy coverage, please contact EnvisionRx Options at (800) Orchard Pharmaceutical Services is continuing to provide mail order prescription drug services. For questions regarding mail order services or to obtain a mail order form, please contact Orchard Pharmaceutical Services at (800) Page 2 of 5

3 Summary of Benefits and Coverage (SBC) and Uniform Glossary Under the Affordable Care Act, group health plans and insurance companies must provide participants with SBCs and a uniform glossary of terms commonly used in health insurance coverage. All group health plans and insurance companies use the same standard SBC and glossary. Our SBC documents are enclosed in this communication. Women s Health and Cancer Rights Act (WHCRA) In 1998, the Women s Health and Cancer Rights Act was signed into law. Group health plans offering mastectomy coverage must also provide coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient. This coverage includes the following. Reconstruction of the breast on which the mastectomy was performed. Surgery and reconstruction of the other breast to present a symmetrical appearance. Prostheses and treatment of physical complications at all stages of the mastectomy procedure, including lymphedemas (swelling of the hand and arm on the operated side). The University of Akron is required to notify employees and retirees of these provisions annually. Despite the name of the act, nothing in the law limits WHCRA entitlements to women only. If you have any questions about this or other healthcare benefits, please contact your health care provider by calling the Customer Service number listed on your insurance identification card. Effective January 1, 2013, the University will add the following preventative care benefits at $0 copay. Annual well-woman preventative care visits for adult women to obtain the recommended preventative services that are age and developmentally appropriate, including preconception and prenatal care Screenings for gestational diabetes at 24 and 28 weeks gestation and at first prenatal visit for pregnant women identified to be at high risk for diabetes Screening at least every three years for human papilloma virus in women age 30 and over Annual counseling for sexually transmitted infections for all sexually active women Annual counseling and screening for human immune-deficiency virus for all sexually active women FDA-Approved contraceptive methods, sterilization procedures, patient education and counseling for all women with reproductive capacity (Brand-name prescription drugs are subject to cost sharing, unless a generic equivalent is unavailable). Breastfeeding support and counseling Annual screening and counseling for interpersonal and domestic violence Fluoride* supplement for preschool children (more than 6months-5years) whose primary water source is deficient in fluoride Removal of $500 lifetime cap for smoking cessation * Prescription Required Page 3 of 5

4 2013 Retiree Dependent Medical & Prescription Drug Plan Summary Under maintenance of benefits with Medicare the secondary plan (SummaCare) calculates the benefit that would be paid as though it were the primary plan, then subtracts the payment of the primary plan (Medicare Part A or B) and pays the difference, if any. No payment will be made by SummaCare if the SummaCare benefit is equal to or less than the Medicare benefit. Medicare typically reimburses 80% of its allowed charges. SummaCare Medicare Supplement Plan Medicare Maintenance of Benefits Preventive Care 100% Office Visit Specialist Physicians Urgent Care Emergency Room Deductible (Single/Family) $200/$400 Typical Co-Insurance Annual Out-of Pocket Max (Single/Family) Lifetime Benefit Maximum $1,500/$3,000 Unlimited Retail (30 Day Supply) Mail Order (90 Day Supply) Generic Prescription Drugs (Tier 1) $10 $25 Preferred Brand Prescription Drugs (Tier 2) 20% ($50 Max) 20% ($125 Max) Non-Preferred Brand Prescription Drugs (Tier 3) 25% ($70 Max) 25% ($175 Max) Specialty Prescription Drugs (Tier 4) 25% ($125 Max) --. Retiree dependents will continue to pay 15% of the premium for their medical and prescription coverage in The monthly premium rates are listed in the charts below. SummaCare will continue to administer the collection of the retiree dependent premium payments in If you have questions regarding billing please contact SummaCare at (800) Category Spouse Only Spouse + Children (Age 0 25) Adult Children (Age 26 & 27) SummaCare Medicare Supplement Plan $44 Per Month $124 Per Month Additional $226 Per Month Page 4 of 5

5 Retiree Dependent Medical & Prescription Drug Insurance Election Form for 2013 If you agree with the election information below, you do not need to submit this form. If you wish to re-enroll a spouse or child onto this plan, please complete the following: Retiree: University ID: For 2013, current plan participants will automatically be enrolled in: Your Coverage Level is: Effective Date: Address: Telephone Number: If you wish to change the automatic election listed above, please select the appropriate box below. Submit this form within 30 days of eligibility. I elect the Medicare Supplement plan administered by SummaCare and prescription drug coverage administered by EnvisionRx Options. Elect Coverage Spouse Only Spouse + Children (Age 0-25) Adult Children (Age 26 & 27) $44 per month $124 per month Additional $226 per month Name Relationship Date of Birth Social Security Number Decline Coverage I decline medical and prescription drug coverage offered by The University of Akron effective in I understand there is no monthly cost for declining coverage and eligible persons may re-enter the plan during a family status change or during the next open enrollment period. By signing this, I attest that only my eligible individuals are covered on this plan. I understand that I may be required to provide evidence of eligibility within 30 days at the request of The University of Akron. I agree to pay the monthly premium within the allotted grace period. I understand this election is effective through December 31, Changes to this election may be made during a family status change event. Signature of Retiree or Retiree Dependent Date Return this form to: The University of Akron, Office of Benefits Administration, 302 Buchtel Common, Akron, Ohio For faster processing, fax to PSoft Entry Date Page 5 of 5