UNITE HERE HEALTH. Summary Plan Description UNITE HERE Staff Health Benefits Plan Plan Unit 173 Actives

Transcripción

1 UNITE HERE HEALTH Summary Plan Description UNITE HERE Staff Health Benefits Plan Plan Unit 173 Actives August 2014 This Summary Plan Description supercedes and replaces all materials previously issued.

2 The Plan Administrator and the agent for service of legal process is the Chief Executive Officer (CEO) of UNITE HERE HEALTH. Service of legal process may also be made on any Plan Trustee. The CEO s address and phone number are: UNITE HERE HEALTH Chief Executive Officer P. O. Box 6020 Aurora, IL (630)

3 INTRODUCTION UNITE HERE HEALTH (the Fund) was created to provide benefits for you and your covered dependents. UNITE HERE HEALTH serves participants working for employers in the hospitality industry and is governed by a Board of Trustees composed of an equal number of union and employer trustees. Your Plan, Plan Unit 173 Actives, has been adopted by the Trustees for the payment of medical, prescription drug, dental, vision, and other health and welfare benefits from UNITE HERE HEALTH. This booklet is your Summary Plan Description (SPD). It is a summary of the Plan s rules and regulations and describes: How you become eligible; When your dependents are covered; What benefits you have; Limitations and exclusions; How to file claims; and How to appeal denied claims. If information contained in the SPD is inconsistent with those rules and regulations, the rules and regulations will govern. No contributing employer, employer association, labor organization, or any individual employed by one of these organizations has the authority to answer questions or interpret any provisions of this Summary Plan Description on behalf of UNITE HERE HEALTH. 3

4 ABOUT PLAN FINANCES Who Pays for Your Benefits? In general, Plan benefits are provided by the money you and your employer are required to contribute to UNITE HERE HEALTH on your behalf and that of your covered dependents. What Benefits Are Provided Through Insurance Companies? The Plan provides the following self-funded benefits: Basic Inpatient and Outpatient Coverage, Comprehensive Medical and Surgical Coverage, Prescription Drug Benefits, Vision Care Benefits, and Dental Benefits. Self-funded means that none of these benefits are funded by insurance contracts. Benefits and associated administrative expenses are paid directly from UNITE HERE HEALTH. However, the Plan insures Life and Accidental Death and Dismemberment Benefits. They are funded and guaranteed under group contracts underwritten by Dearborn National. The Plan also maintains contracts to help administer certain benefits. Prescription Drug Benefits are administered by Catamaran; Dental Benefits are administered by Delta Dental of Illinois; and Vision Benefits are administered by Davis Vision, Inc. In addition, specialist referral services, pre-notification and utilization review services, case management, and disease management for the Plan s Medical and Surgical Benefits are provided under the Coordinated Health/Care program administered by Quantum Health. The Plan contracts with Kaiser Permanente to provide a fully insured Health Maintenance Organization (HMO) option. 4

5 HOW TO GET HELP Care Coordinators (866) Call Coordinated Health/Care You can reach a Care Coordinator from 8:30 AM to 10:00 PM (Eastern Time) For pre-notification and specialist referrals; To designate a primary healthcare provider; With questions about your benefits; With questions about your eligibility; With claims status questions; To report changes in employment or family status; To request new ID cards; To get forms and SPDs; and To find a network provider. Mandatory Pre-Notification For hospital admissions and certain procedures (see pages 21-28), call the Care Coordinators before treatment. For emergency hospital treatment, call the Care Coordinators the first business day following admission. Pre-notify the Care Coordinators before you get any care other than in your healthcare professional s office. (866) $150 penalty may apply if you do not call! Your PPO Network BlueCross BlueShield of Illinois (800) 810-BLUE (2583) Your Prescription Drug Network Catamaran (866) Your Dental Network Delta Dental (800) You can also visit the UNITE HERE HEALTH website to find enrollment or election forms, claim forms, get a copy of your SPD, or request additional information: UNITE HERE HEALTH UNITE HERE Staff Plan Benefits 711 N. Commons Aurora, IL (866) (855) FUNDTTY ( ) for TTY visit our website at Este libro es un resumen, en inglés, de sus derechos y beneficios bajo su Plan, Unidad de Plan 173. Si Usted tiene dificultad comprendiendo cualquier parte de este libro, comuníquese a la Oficina para asistencia. Número gratuito (866) La oficina está abierta de lunes a viernes desde las 8:30 A.M. hasta las 10:00 P.M. (tiempo del Este). 5

6 TIPS FOR USING YOUR BENEFITS Get a PCP You and each of your dependents should have a primary care provider (PCP). You should get to know your PCP so he or she can help you get, and stay, healthier. Your PCP can observe your overall health, answer questions for you, and help coordinate your care. He or she can also help you get specialist care when appropriate. Make sure your PCP calls the Care Coordinators before your first visit to the specialist. You will pay an extra $10 if your specialist visit is not referred in advance. Your PCP can also help you track when you need preventive care. Call the Care Coordinators at (866) for help finding a PCP. Get Preventive Care Your Plan pays 100% for certain kinds of preventive care (see pages 41-43). Getting recommended preventive care can help you stay healthy, and help your PCP find out if you may be developing a health condition. Re-Think Emergency Room Care Is it really an emergency? If not, you will pay less for a visit to an urgent care center. You only pay $20 per visit to a network urgent care center. If you use a hospital emergency room, and it s not a true emergency, you will pay 20% of the allowable charges for the emergency room care. See page 31 for a definition of emergency. If you think you are having an emergency, call 911 or go to the emergency room. 6

7 TIPS FOR USING YOUR BENEFITS Call the Care Coordinators The Care Coordinators are here to help you. They can help you find a provider, answer questions about your Plan or medical care, get you in touch with a nurse, help coordinate your care, and answer other questions for you. See pages for more information about the Coordinated Health/Care program. Call the Care Coordinators at (866) Use Network Providers Generally, you pay less for your and your dependents care when you use network providers. Typically, network providers charge less than non-network providers. Plus, the Plan usually pays more for covered services and supplies when provided by network providers and hospitals. BlueCross BlueShield of Illinois provides access to a national network of doctors, hospitals, and other healthcare providers. Catamaran provides access to a national network of pharmacies that you must use in order to get benefits for prescription drugs. Davis Vision provides access to a national network of vision care providers. Delta Dental provides access to a national network of dental care providers. See page 5 for contact information for the Plan s service providers. If you have questions about your benefits, call toll free: The Care Coordinators at (866)

8 TABLE OF CONTENTS This Table of Contents is designed to help you find specific benefit information easily and quickly. Look for the question that best describes what you want to know. Where Does the Money to Pay Benefits Come From? About Plan Finances Who Pays for Your Benefits? What Benefits Are Provided Through Insurance Companies? What If I Need More Information? How to Get Help What is the Best Way to Use My Benefits? Tips for Using Your Benefits Get a PCP Get Preventive Care Re-Think Emergency Room Care Call the Care Coordinators Use Network Providers What Health and Welfare Benefits Does the Plan Provide? Benefits at a Glance Who s Covered by the Plan? Who s Eligible Employees Dependents Who Your Dependents Are Enrollment Employees Enrolling Your Dependents Enrollment Form Dependent Documentation Paying for Dependent Coverage Enrollment in HMO Coverage Enrollment Periods Open Enrollment Periods Special Enrollment Periods

9 TABLE OF CONTENTS Is There an HMO Option? HMO Option How to Use Kaiser HMO Coverage The Effect of Choosing Kaiser HMO Coverage What Cost Containment Programs Does UNITE HERE HEALTH Use? PPO Plan s Coordinated Health/Care Referrals for Specialists Network Specialist Care Non-Network Specialist Care Pre-Notification for Medical and Surgical Treatment Hospital Admissions Outpatient Services and Supplies $150 Penalty Prenatal Care Case Management Program Disease Management Program Processing Requests for Pre-Notification of Benefits If More Time Is Needed If Additional Information Is Needed Special Rules for Decisions Involving Concurrent Care If Pre-Notification Results in Denied Benefits Appealing the Denial of Benefit Certification How Does the Plan Decide How Much to Pay? How Plan Benefits Are Determined Injuries and Sicknesses Allowable Charges Medically Necessary Care and Treatment Treatment by Network and Non-Network Healthcare Professionals and Hospitals Definition of Healthcare Professional Emergency Medical Treatment What Basic Services Does the Plan Cover? PPO Plan s Basic Inpatient and Outpatient Benefits What the Plan Pays Network Services Non-Network Services What You Pay The Calendar Year Deductible Family Deductible Limit What s Covered What s Not Covered

10 TABLE OF CONTENTS What Medical or Surgical Services Does the Plan Cover? PPO Plan s Comprehensive Medical and Surgical Benefits What the Plan Pays What You Pay Copayments About the Deductibles Family Deductible Limit Out-of-Pocket Spending Limit (Network Services Only) What s Covered Preventive Healthcare Services Covered at 100% When Network Providers Are Used What s Not Covered Does the Plan Provide Prescription Drug Benefits? PPO Plan s Prescription Drug Benefits What You Pay Generic Drug Policy What s Covered Prior Authorization Mail Order Refills Dispensing Limitations Quantity Limit Program What s Not Covered Processing Requests for Pre-Authorization If More Time Is Needed If Additional Information Is Needed If a Request for Pre-Authorization Is Denied Appealing the Denial of a Request for Pre-Authorization What Dental Services Does the Plan Cover? Dental Benefits What the Plan Pays What You Pay Delta Dental PPO and Delta Dental Premier Dentists Non-Participating Dentists Alternate Course of Treatment What s Covered Frequency of Service Limitations What s Not Covered Predetermination of Dental Benefits Dental Benefits after Eligibility Ends

11 TABLE OF CONTENTS What Vision Care Services Does the Plan Cover? Vision Care Benefits What s Covered Frequency Limitation What the Plan Pays What You Pay What s Not Covered What Services and Supplies Are Not Covered at All? General Exclusions and Limitations What If I m Also Covered Under Another Healthcare Plan? Coordination of Benefits Which Plan Pays First Order of Payment COB and Pre-Notification Husband and Wife, or Domestic Partners, Under This Plan When Must Plan Payments Be Returned? Subrogation The Plan s Right to Recover Payments When Injury Is Caused by Someone Else Statement of Facts and Repayment Agreement Settling Your Claim What If I Die? Life and Accidental Death & Dismemberment Insurance Benefit Life Insurance Benefit Continuation if You Become Totally Disabled Converting to Individual Life Insurance Coverage Accidental Death & Dismemberment Insurance Benefit AD&D Exclusions Naming a Beneficiary Filing a Claim Additional Insurance Benefits and Services Accidental Death & Dismemberment Insurance Benefits Life Insurance Benefits How Do I Become Eligible For and Then Continue Coverage? Eligibility for Coverage When Your Coverage Begins Continuing Eligibility When Dependent Coverage Begins Existing Dependents Additional Dependents

12 TABLE OF CONTENTS When Does Coverage End? Termination of Coverage When Employee Coverage Ends When Dependent Coverage Ends Retroactive Terminations of Coverage Certificate of Creditable Coverage The Effect of Delinquent Employer Contributions When Your Employer s Collective Bargaining Agreement Expires If You Are Disabled When Coverage Ends What If I Lose Coverage and Then Return to Work? Re-Establishing Eligibility Re-Establishing Employee Coverage Re-Establishing Dependent Coverage Portability Family and Medical Leave Act The Effect of Uniformed Service How Can Coverage Be Continued? COBRA Continuation Coverage Who Can Elect COBRA Coverage? What Is a Qualifying Event? What Coverage Can Be Continued? How Long Can Coverage Be Continued? Termination of COBRA Coverage Notifying UNITE HERE HEALTH When Qualifying Events Occur Election and Payment Deadlines How Do I File a Claim and What Do I Do If It s Denied? General Claim Provisions Filing a Benefit Claim Healthcare Claims Dental Claims Vision Claims (Non-Network Providers) All Other Benefit Claims Deadlines for Filing a Benefit Claim Individuals Who May File a Benefit Claim Who Is an Authorized Representative? Filing a Claim for Covered Services Furnished in Canada Medical Benefit Claims Prescription Drug Benefit Claims Dental Benefit Claims Vision Benefit Claims

13 TABLE OF CONTENTS Payment of Claims Concurrent Care Decisions Life Insurance Benefit Claims Healthcare Claims Not Involving Concurrent Care Decisions If a Benefit Claim Is Denied Special Rules for Denials of Prescription Drug Card Benefits Appealing the Denial of a Claim Claims Subject to Two Levels of Appeal First Level of Appeal Final Level of Appeal Claims Subject to One Level of Appeal Appeals to UNITE HERE HEALTH Involving Urgent Care Claims Appeals Under the Sole Authority of the Plan Administrator Review of Appeals Notice of UNITE HERE HEALTH s Decision on Your Appeal Independent External Review Procedures What Else Do I Need to Know? Other Important Information Interpretation of Plan Provisions Kaiser HMO Benefits Independent Review Organization All Other Authority Rests with the Board of Trustees Amendment or Termination of the Plan Providers Workers Compensation Type of Plan Plan Administrator Employer Identification Number Plan Number Plan Year Remedies for Fraud Your Rights Under ERISA Receive Information about Your Plan and Benefits Continue Group Health Plan Coverage Creditable Coverage Prudent Actions by Plan Fiduciaries Enforce Your Rights Assistance with Your Questions Board of Trustees Provider Organization Phone Numbers and Addresses

14 BENEFITS AT A GLANCE Please call the Care Coordinators at (866) if you have specific questions about covered services. Here is a summary of your welfare benefits. Please call toll free at (866) if you have specific questions about covered services. In general, Plan benefits distinguish between treatment furnished by network providers and treatment furnished by non-network providers, as shown in the following table. The Comprehensive Major Medical benefit pays a percentage of the Plan s allowable charges for covered medical expenses. You are responsible for paying the deductible, copayments, your share of allowable charges the Plan doesn t pay, any amount over any maximum benefits, and any expenses that are not covered by the Plan. Calendar Year Deductible Applies to non-network Basic Inpatient and Outpatient Benefits as well as non-network Comprehensive Major Medical Benefits. No deductible applies to network provider services, treatment in a hospital emergency room, certain outpatient services furnished by a licensed diabetes educator, and outpatient nutrition counseling services, and the following services furnished by non-network providers: anesthesiology, well baby care, mammography, prenatal care approved under the Plan s Coordinated Health/Care (see pages 21-28), and second or third surgical opinions. Individual $200 Family $400 Basic Inpatient and Outpatient Benefits What You Pay Benefit Description Network Providers Non-Network Providers Hospital Inpatient Services No charge 20% Hospital Outpatient Services No charge 20% Diagnostic Services No charge 20% Mammography Subject to frequency limitations No charge 20% Ambulatory Surgical Facility Services No charge 20% Skilled Nursing Facility Accommodations Up to a combined network / non-network 70-day calendar year maximum No charge 20% Hospice Services 210-visit maximum based on guidelines No charge 20% Home Health Services Up to a combined network / non-network 200-visit calendar year maximum No charge 20% Emergency Room Treatment True emergency No charge No charge; no deductible Emergency Room Treatment Non-Emergency 20% 40% Coordinated Health/Care Program Includes hospital pre-admission notification, emergency admission review, pre-notification of certain medical procedures, treatments, and supplies, and retrospective review. Call The Care Coordinators toll free at (866) $150 penalty applies if you don t call when required. If your claim is not medically necessary, no benefits will be paid. Calling the Care Coordinators will help you determine if your claim is medically necessary. 14

15 BENEFITS AT A GLANCE Comprehensive Medical and Surgical Benefits What You Pay Benefit Description Network Providers Non-Network Providers Primary Care Provider Office Visit No charge after $10 copay 20% Specialist If referred by your Primary Care Provider No charge after $10 copay 20% Specialist If NOT referred by your Primary Care Provider No charge after $20 copay 20% Preventive Healthcare See pages for a list of covered preventive care services No charge 20% Well Baby Care Up to 18 months of age No charge 20%; no deductible Clinic or Urgent Care Services No charge after $20 copay 20% Chiropractic Services No charge after $15 copay 20% Podiatric Services No charge after $15 copay 20% Alcohol / Substance Abuse Services, Outpatient No charge after $10 copay 20% Mental Health Services, Outpatient No charge after $10 copay 20% Professional Services, Inpatient, Surgical, Maternity No charge 20% Healthcare Professional Services, Non-Emergency in Hospital Emergency Room 20% 40% Acupuncture Professional Ambulance Transportation No charge after $15 copay; up to 25 visits per year No charge after separate $100 calendar year deductible 20%; up to 20 visits per year 20% after separate $100 calendar year deductible Non-Replaced Blood and Blood Plasma After deducting the cost of the first pint Private Duty Nursing Subject to calendar year deductible and up to a combined network / non-network $20,000 calendar year maximum 10% after separate $100 calendar year deductible 20% 20% Out-of-Pocket Spending Limit Once you incur out-of-pocket costs for network copays, deductibles, and certain other covered network expenses, network benefits for the rest of the year are paid at 100% (see page 40) $6,350 per person; $12,700 per family N / A Prescription Drug Benefits What You Pay Only available at participating TrueChoice Pharmacies For a retail 34-day supply For a mail order 60-day supply Generic Drugs $15 $10 Preferred Brand Name Drugs on the Catamaran Formulary $25 $10 Other Brand Name Drugs not on the Catamaran Formulary $35 $35 Dental Benefits What You Pay $5,000 annual maximum (does not apply to exams for children under age 19). You will pay any amounts over the allowable expense (see pages 55-61). Description of Services Network Dentists Non-Network Dentists Preventive and Diagnostic Services No charge No charge Minor Restorative Services No charge No charge Major Restorative Services No charge No charge Orthodontic Services No charge No charge Vision Care Benefits What You Pay Network Vision Services Non-Network Vision Services No charge for eye exams, covered lenses, or Tower Collection frames The plan pays up to $250; you must pay any additional expenses 15

16 IN THIS SECTION 16 EMPLOYEES 16 DEPENDENTS 17 ENROLLMENT 18 PAYING FOR DEPENDENT COVERAGE 18 ENROLLMENT IN HMO COVERAGE 18 ENROLLMENT PERIODS WHO S ELIGIBLE The information beginning on page 76 will help you figure out when you are eligible for benefits. Employees You are eligible for coverage if: You work for an employer who is required by a Participation Agreement to contribute to UNITE HERE HEALTH on your behalf; The necessary contributions are received by UNITE HERE HEALTH; and You satisfy the Plan s eligibility rules. There may be tax consequences to Domestic Partner Coverage. Contact your employer for more information. Dependents Your dependents become eligible for coverage on the date you become eligible or on the date you acquire your first dependent, which ever happens last. You do not have to contribute toward the cost of coverage for your dependents. Who Your Dependents Are For benefit purposes, your dependents are: Contact your employer or UNITE HERE HEALTH for an Affidavit of Domestic Partnership. Your husband or wife, but only if there is a valid marriage license or marriage certificate; Your domestic partner, but only if there is a valid Affidavit of Domestic Partnership; Your natural children, step-children, adopted children, children placed with you for adoption and for whom you are legally required to provide support until the adoption is finalized, children entitled to coverage because of a Qualified Medical Child Support Order, or children for whom you are awarded legal guardianship or sole custody pursuant to state domestic relations law, who are under age 26. To be covered on or after their 26th birthday, your unmarried children must be unable to support themselves because of a mental or physical handicap that began before age 19 and while covered by the Plan on the day prior to their 19th birthday. See page 78 for details. 16

17 WHO S ELIGIBLE Enrollment Employees Once you have become eligible, coverage is automatic. However, you still need to fill out and submit an enrollment form. Enrolling Your Dependents When you qualify for Dependent Coverage you must enroll all dependents you want covered by the Plan, including dependents acquired after Dependent Coverage becomes effective, by submitting the enrollment materials described in this section. No medical benefits can be provided to dependents until you submit the required enrollment material to the Fund Office. Federal law requires UNITE HERE HEALTH to honor Qualified Medical Child Support Orders. UNITE HERE HEALTH has established procedures for determining whether a divorce decree or a support order meets federal requirements and for enrollment of any child named in the Qualified Medical Child Support Order. To obtain a copy of these procedures at no cost, or for more information, contact UNITE HERE HEALTH. Enrollment Form To enroll your dependents you must complete and submit an enrollment form. The information required includes: Your information: name, Social Security number, birth date, home address, phone number, employer name, hire date. Dependent information: name, Social Security number, birth date. The Dependent Enrollment Form must be submitted to UNITE HERE HEALTH within 30 days after the date you become entitled to elect Dependent Coverage. Coverage for your dependents cannot begin before your coverage begins. Dependent Documentation In order to verify a person s dependent status, in addition to the completed enrollment form, you must also provide, as appropriate, at least one of the following: A certified copy of your marriage license or marriage certificate; A commemoration of marriage issued by a generally recognized denomination of organized religion; A certified copy of the birth certificate; Baptismal certificate; Hospital birth records; Written proof of adoption or legal guardianship; Copies of court decrees that obligate an employee to provide medical benefits for a dependent child; Notarized copies of a participant s most recent Federal Income Tax return (Form 1040 or its equivalents); Certificates of Creditable Coverage issued in accordance with the provisions of the Health Insurance Portability and Accountability Act of 1996, as amended; Documentation of dependent status issued and certified by the United States Immigration and Naturalization Service; or Documentation of dependent status issued and certified by a foreign embassy. Once you have Dependent Coverage, coverage for newly acquired dependents will begin as soon as they qualify as dependents. For example, newborn children are covered from birth. However, you must still enroll newly acquired dependents and submit the required proof to the Fund Office. English translations for all documents must be provided as required. 17

18 WHO S ELIGIBLE If any of the preceding documents are used to verify the dependent status of a child, they must contain the names of the child s parents. Paying for Dependent Coverage Coverage for your dependents is available at no cost to you as long as employer contributions continue to be made for you and your covered dependents and you continue to meet the work requirements necessary to maintain your eligibility. Enrollment in HMO Coverage If you and your family live in California, you may be able to enroll in the HMO coverage option. See pages for more information about HMO coverage. You will have the opportunity to enroll in the HMO once you become eligible. After you enroll, you will only be able to change to or from the HMO during an Open Enrollment, period, or if you have a Special Enrollment Period. Enrollment Periods This section only applies if you are switching from the PPO option to the HMO option, or vice versa. Remember, the HMO option is only available if you live in California. Open Enrollment Periods Open Enrollment Periods take place as designated by the Plan. They provide you with the opportunity to change your coverage option (PPO option or HMO option). Special Enrollment Periods You may be able to change your and your dependents coverage option before the next Open Enrollment Period, if one of the following events occurs, as long as you enroll within 60 days of the date of the event: Termination of other group health coverage, including COBRA continuation coverage, that you had when you first became eligible for coverage under UNITE HERE HEALTH, unless that coverage ended because required premium payments were stopped; Your marriage; The birth of your child; The adoption or placement for adoption of a child under age 26; A dependent who used to live in a foreign country comes to the United States and takes up residence with you; You or your lose eligibility for Medicaid or Child Health Insurance Program benefits; or You or your dependent gain eligibility for state financial assistance under a Medicaid or Child Health Insurance Program to help pay for the cost of UNITE HERE HEALTH. If you do not take advantage of a Special Enrollment Period, you may have to wait until the next Open Enrollment Period to change your medical coverage option. 18

19 IN THIS SECTION 19 HOW TO USE KAISER HMO COVERAGE 19 THE EFFECT OF CHOOSING KAISER HMO COVERAGE HMO OPTION If you live in California, you may be eligible for the HMO benefit option through Kaiser Permanente. UNITE HERE HEALTH has contracted with Kaiser Permanente (Kaiser) to provide health maintenance organization (HMO) benefits for you and your enrolled dependents. When you become eligible to enroll in UNITE HERE HEALTH, you will receive an enrollment packet highlighting the Kaiser benefit. In order to enroll, you must complete the forms included in the enrollment packet. If you choose to enroll in Kaiser, you will get a Kaiser booklet (a certificate of coverage) describing your Kaiser benefits. How to Use Kaiser HMO Coverage If you enroll in the Kaiser HMO option, you should choose a primary care provider (PCP). Your primary care provider will help you get care through Kaiser. For example, you will need a referral from a Kaiser provider to see most specialists. Your primary care provider can do this for you. You do not need a referral or prior authorization to receive obstetrical or gynecological care from a Kaiser-contracted healthcare professional who specializes in obstetrics or gynecology. Except in emergencies, you will usually be required to use a Kaiser provider, Kaiser hospital, or Kaiser facility in order to receive benefits. Kaiser Permanente Member Services: (800) Kaiser Advice Nurse: (888) KPONCALL ( ) When you choose a primary care provider, you may choose any Kaiser provider available. You may also choose a Kaiser pediatrician as the primary care provider for a child. You can get more information about your Kaiser benefits by calling Kaiser, or from your Kaiser enrollment materials. For more information about your HMO benefits call: Kaiser Permanente at (800) The Effect of Choosing Kaiser HMO Coverage The contract between UNITE HERE HEALTH and Kaiser Permanente will govern how Kaiser benefits are paid. If there is any discrepancy between any information about the Kaiser benefits provided by UNITE HERE HEALTH and the Kaiser contract, the Kaiser contract will govern. 19

20 HMO OPTION In addition, the contract between UNITE HERE HEALTH and Kaiser governs how benefits are paid and administered. That means that the Kaiser certificate of coverage you get when you enroll in one of the Kaiser options will explain the rules that apply to your benefits. Several sections of this SPD do not apply to you if you are enrolled in the Kaiser HMO option, including: PPO Plan s Coordinated Healthcare; How PPO Plan Benefits are Determined; PPO Plan Comprehensive Major Medical Benefits; and PPO Plan Prescription Drug Benefits. In addition, if you are enrolled in the Kaiser HMO, the following sections only apply to those benefits not provided through Kaiser. General Exclusions and Limitations; Coordination of Benefits; Subrogation; and General Claim Provisions. The Kaiser certificate of coverage will give you more information about your medical management programs, your medical and prescription drug benefits, coordination of benefits, exclusions and limitations, subrogation, and claims provisions, including filing claim appeals. 20

21 IN THIS SECTION 22 REFERRALS FOR SPECIALISTS 23 PRE-NOTIFICATION FOR MEDICAL AND SURGICAL TREATMENT 24 OUTPATIENT SERVICES AND SUPPLIES 26 PRENATAL CARE 26 CASE MANAGEMENT PROGRAM 26 DISEASE MANAGEMENT PROGRAM PPO PLAN S COORDINATED HEALTH/CARE 27 PROCESSING REQUESTS FOR PRE-NOTIFICATION OF BENEFITS 27 SPECIAL RULES FOR DECISIONS INVOLVING CONCURRENT CARE 28 IF PRE-NOTIFICATION RESULTS IN DENIED BENEFITS If you and your family live in California, you have the choice of enrolling in the PPO Plan or in the Kaiser HMO option. This section only applies to members enrolled in the PPO Plan option. If you are enrolled Kaiser, see your Kaiser booklet for more information about medical management review. Coordinated Health/Care is a utilization management program includes a staff of Care Coordinators who coordinate both your healthcare and the information flow between healthcare professionals and providers. You should contact the Care Coordinators any time you or your dependents before receiving most healthcare services other than those provided by your Primary Care Provider (PCP). The Coordinated Health/Care utilization management program includes: A specialist care referral program; Required pre-notification of certain treatments and procedures; Required utilization review and concurrent care review; A voluntary case management program; and A voluntary disease management program. The Coordinated Health/Care program is intended to help you and your dependents get quality healthcare and services in the most appropriate setting, help reduce unnecessary medical care, and identify complex medical conditions. Care Coordinators also are available to answer your questions and to provide information to you and your providers. Call the Care Coordinators toll free between 8:30 a.m. to 10:00 p.m. (Eastern time): Coordinated Health/Care at (866)

22 PPO PLAN S COORDINATED HEALTH/CARE A primary care provider (PCP) is a healthcare professional who specializes in: Family medicine, General practice, Internal medicine, Pediatrician (for children), or An OB/GYN while you or a dependent is pregnant. Coordinated Health/Care is not intended as and does not constitute medical advice. UNITE HERE HEALTH is not responsible for any consequences resulting from decisions you or your healthcare professional make based on the Coordinated Health/Care program or the Plan s determination of the benefits it will pay. It is your responsibility to see that the notice and information requirements of Coordinated Health/Care are followed. However, you, your healthcare professional, or a member of your immediate family can provide the notice and information. Referrals for Specialists Although your PCP should contact the Care Coordinators with referrals to specialists, it is your responsibility to make sure the Care Coordinators get the referral. Contact the Care Coordinators to check on the status of a referral. The specialist referral program does not apply to: preventive care, chiropractic care, podiatric care, physical, occupational, or speech therapy, treatment of mental health or substance abuse, or to non-network providers. However, you should still contact the Care Coordinators before receiving any of these types of care. Under the Coordinated Health/Care program, you are encouraged to choose a primary care provider (PCP) for yourself and for each of your covered dependents. You and each of your dependents can have the same PCP, or choose different PCPs. Contact the Care Coordinators to designate a PCP. You can change your PCP designation at any time. If you don t have a PCP, the Care Coordinators can help you find one. You will receive the highest level of benefits if you choose a network healthcare professional as your PCP. Under the Coordinated Health/Care program, you are encouraged to use your PCP for ongoing guidance and coordination of your healthcare. If you need to see a specialist, your PCP should contact the Care Coordinators to make a referral. Care Coordinators may coordinate your care with your PCP, and send your PCP with information about healthcare services you receive. Once your PCP has contacted the Care Coordinators, the Care Coordinator will send you a letter verifying that the specialist referral is in place, and the time period or number of visits requested by your PCP. No further referrals for a particular type of specialist are necessary during the time period or number of visits the Care Coordinators have approved. 22

23 PPO PLAN S COORDINATED HEALTH/CARE Network Specialist Care If a PCP refers you to a network specialist, your network specialist office visit copay will be $10. Any PCP can make this referral, including a non-network PCP. If a PCP does not refer you to a specialist, your office visit copay for a network specialist will be $20. If you see the specialist before your PCP provides a referral to the Care Coordinators, the $20 copay will apply, even if your PCP later provides the referral. Although an OB/GYN is not considered a PCP unless you are pregnant, a $10 copay will apply to each network OB/GYN office visit (unless the services are for covered preventive care see pages 41-43). However, you should encourage your PCP to contact the Care Coordinators if you are not pregnant and need to see an OB/GYN. Non-Network Specialist Care Non-network office visits for a specialist are subject to any applicable deductibles and coinsurance. See your Benefits at a Glance on pages for more information about your benefits. You should still ask your PCP to contact the Care Coordinators prior to referral to a non-network specialist. Pre-Notification for Medical and Surgical Treatment Coordinated Health/Care also provides a pre-notification program for medical and surgical utilization including: hospital pre-admission pre-notification, emergency admission review, concurrent review, pre-notification of certain outpatient medical procedures, treatments, and certain durable medical equipment and retrospective review when pre-notification or authorization is not provided. You should contact Coordinated Health/Care prior to receiving any of the services or supplies listed below. A $150 penalty may apply, or benefits may be denied entirely, if you do not follow the rules described in this section. Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or a newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a caesarean section. However, federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). For pre-notification services, call toll free: Coordinated Health/Care at (866) Pre-notification, referral or authorization under Coordinated Health/Care does not guarantee eligibility for benefits or that benefits will be payable for treatment or services provided. Failure to follow the requirements of Coordinated Health/Care may cause a $150 penalty. In addition, all claims are reviewed to be sure they meet the plan s requirements. If they do not meet the requirements, no benefits will be paid. It is recommended that you contact the Care Coordinators in advance of a maternity admission, preferably at least 30 days prior to the expected delivery date. 23

24 PPO PLAN S COORDINATED HEALTH/CARE Hospital Admissions For all non-maternity hospitalizations, including skilled nursing facility care and hospital admissions for transplants, you, a family member, or your healthcare professional must contact the Care Coordinators as described below. A $150 penalty applies if the Care Coordinators are not contacted: For all non-emergency confinements, any time prior to admission. It is recommended that you contact the Care Coordinators at least three days before a scheduled admission. You can also call earlier if your healthcare professional recommends a scheduled hospital admission. For all emergency or urgent care confinements, the first business day following admission. However, the $150 penalty will not apply if: It was not reasonable to meet the deadline, and The Care Coordinators were notified as soon as reasonably possible. UNITE HERE HEALTH has the final say in determining if it was reasonable to meet the deadline and if the required notification was made as soon as reasonably possible. For maternity hospitalizations, benefits must be certified for any lengths of stay exceeding: 48 hours for the normal delivery of a newborn child; or 96 hours for the delivery of a newborn child by caesarean section. Outpatient Services and Supplies Contact a Care Coordinator at (866) for care outside your PCP s office. Why? It will help your Fund pay your healthcare costs. If you don t, your benefits may be reduced by $150 or denied entirely. You should contact a Care Coordinator before you get care other than in a healthcare professional s office. You or your healthcare professional should contact the Care Coordinators before you or your dependents receive any of the services listed below: Outpatient surgery (other than surgery performed in a healthcare professional s office); Durable medical equipment rental or purchases of $500 or more (including breast pumps); Home healthcare; Hospice care; Speech, occupational, and physical therapy; Oncology services, including but not limited to radiation therapy and chemotherapy; Dialysis; Genetic testing; The following diagnostic imaging procedures: MRA (Magnetic Resonance Angiography), MRI (Magnetic Resonance Imaging), PET-Scan (Positron Emission Tomography Scintiscan) and PET-CT; and Transplants. Transplants must be preapproved in writing or benefits will be denied. 24