Transcript Health Care - UAW-GM Center For Human Resources

Health Care
2014 Joint Benefit Plans Conference
Health Care
Welcome & Introductions
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Health Care
Agenda
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Assessment
2013 Health Care Spend
The Patient Protection & Affordable Care Act (PPACA)
Program Structure
Health Care Eligibility
Health Maintenance Organizations (HMOs)
Hospital, Surgical and Medical Coverage
Prescription Drug Coverage
Hearing Aid Coverage
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Health Care
Agenda
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Mental Health & Substance Abuse Coverage
Dental Coverage
Vision Coverage
LifeSteps/Wellness Overview
FSA’s (Health Care and Dependent Care Reimbursement Plans)
Health Insurance Portability Accountability Act (HIPAA)
Appeals Process
Q&A
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Health Care
Assessment
 Under PPACA, an employee will be covered under the group
health care medical plan on the 91st day that they are actively at
work.
A) True
B) False
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Health Care
Assessment
 Required documents for adding a dependent to substantiate
eligibility, must be provided to the GM Benefits and Service
Center within 30 days.
A) True
B) False
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Health Care
Assessment
 Dependent Children by Legal Guardianship are covered under
PPACA in such that they are covered under group health care
medical up until age 26.
A) True
B) False
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Health Care
Assessment
 Social service guidance, dietary guidance, and functional
occupational therapy are generally services covered under
Home Health Care Coverage.
A) True
B) False
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Health Care
Assessment
 Flexible Spending Accounts – Health Reimbursement Plan are a
covered benefit for Entry Level and Flex employees.
A) True
B) False
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Health Care
2013 GM Hourly Active Health Care Spend
Coverage
Total ($Mils)
Medical
$389
Pharmacy
$115
Behavioral Health
Health Maintenance Organization (HMOs)
$13
$118
Dental
$45
Vision
$3
TOTAL
$682
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Health Care
Program Structure
 Article I – Establishment, Financing & Administration
 Article II – Health Care Coverages
 Article III – Enrollment, Eligibility, Commencement,
Contributions & Continuation
 Article IV – Definitions
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Health Care
Program Structure
 Appendix A – Hospital, Surgical, Medical
Coverages
 Appendix B – Mental Health and
Substance Abuse
= “Medical Plan”
 Appendix C – Dental Coverages
= “Dental Plan”
 Appendix D – Vision Coverages
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= “Vision Plan”
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Health Care
Program Structure
 Appendix E – Supports definition of “employee” for inclusion
into the Program
 Appendix F – Entry Level Health Care Plan
 Appendix G – Flex Health Care Plan
 Miscellaneous Letters of Agreement
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Health Care
The Patient Protection and Affordable Care
Act (PPACA)
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Health Care
The Patient Protection and Affordable Care Act
 90-Day Waiting Period Limitation
– Effective for plan years beginning on or after January 1, 2014, a group
health plan cannot apply any waiting period that exceeds 90 days
– Coverage will become effective on the 91st calendar day whether the
employee is at work or not, normal continuance rules will then follow
– Requirement does not apply to Dental and Vision Plans that are
“excepted benefits”
• The Hourly Entry Level Dental and Vision Plans are considered “excepted
benefits”
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Health Care
The Patient Protection and Affordable Care Act
 Yellow highlights show 91st calendar day eligibility by coverage
Coverage
Traditional
Entry Level
Flex
Temporary
Medical
91st calendar day
91st calendar day
91st calendar day
Not eligible
Dental
91st calendar day
Not Applicable – Eligibility is first day of
the month following the month in which
the employee is actively at work after
acquiring three (3) years of seniority
Not eligible
Not eligible
Not Applicable – Eligibility is first day of
the month following the month in which
the employee is actively at work after
acquiring three (3) years of seniority
(eye exam only); full vision coverage
after five (5) years seniority
Not eligible
Not eligible
Vision
91st calendar day
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Health Care
The Patient Protection and Affordable Care Act
 Notice of Exchanges/Marketplace
– Notice was sent to all employees in September, 2013 (one-time written
notice)
– Informs employees about:
• The Health Insurance Marketplace
• Potential lower cost health care options in the Marketplace including tax
credits, depending on their income and what coverage may be offered by
their employer
• Potential loss of employer contribution to their health benefits, if they buy
insurance through the Marketplace
– New employees will receive the notice through the on-boarding process
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Health Care
The Patient Protection and Affordable Care Act
 Consolidated Omnibus Budget Reconciliation Act (COBRA)
Notice
– In May 2014, the Department of Labor issued proposed rules to update
the model COBRA notices
– The Department of Health and Human Services is concerned that the
former model COBRA notices do not sufficiently address Marketplace
options
– This is the second update to the COBRA notices outlining the
Marketplace options
– The updated GM COBRA notices were implemented in June, 2014
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Health Care
The Patient Protection and Affordable Care Act
 Individual Shared Responsibility Payment/Individual Mandate
– Effective January 1, 2014, PPACA requires individuals and each
member of their family to have qualifying health insurance (called
minimum essential coverage) or pay a tax penalty
• The penalty does not apply during the 90-day waiting period
• The GM Hourly Health Care Plans are considered “minimum essential
coverage”
• For information regarding the tax penalty and certain exemptions, visit
www.HealthCare.gov
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Health Care
The Patient Protection and Affordable Care Act
 Health Insurance Exchanges/Marketplace Update
– ~10M Americans have signed up
− ~28% of the people signing up for coverage are between the ages of 18
and 34; much lower than the 40% benchmark
− Initial enrollment stats:
Plan
% Enrollment
Actuarial Value (a)
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Silver
65%
70%
Bronze
20%
60%
Gold
9%
80%
Platinum
5%
90%
Catastrophic
1%
Below 60%
(a) Average share of medical spending that
is paid by the plan
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Health Care
Health Care Eligibility
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Flex
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Health Care
Dependent Child Eligibility Provision
Article III, 9 (c) (6)
 Effective January 1, 2011 in accordance with Patient Protection
and Affordable Care Act, (PPACA), dependent children by birth
or legal adoption of the primary enrollee or spouse of the
primary enrollee must meet the following requirements:
– the child to be under the age of 26 (coverage ceases at the end of
the month in which the child turns age 26), or
– the child that is “totally and permanently disabled "and became
disabled prior to the end of the calendar year in which the child
turns age 24
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Health Care
Dependent Child Eligibility Provision
 The following eligibility requirements are not required under
PPACA:
– Full-time student status for a child beyond age 19 but not beyond
the end of the calendar in which age 24 is attained,
– Marriage – the child must be unmarried, and
– Residency – the child must reside with the primary enrollee, or the
primary enrollee must be legally responsible for providing health
care coverage.
 Does not apply to dependent children of an eligible same-sex
domestic partner or legal guardianship
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Health Care
Dependent Child Eligibility Provision
 Dependent Children by Legal Guardianship and Eligible SameSex Domestic Partners are required to:
– meet eligibility requirements found in Article III, 9 (c):
• Full-time student status for child beyond age 19 but not beyond the end
of the calendar in which age 24 is attained
• Marriage – the child must be unmarried
• Residency – the child must reside with the primary enrollee, or the
primary enrollee must be legally responsible for health care coverage
 NOT covered under the Patient Protection and Affordable Care
Act, Article III, 9 (6)
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Flex
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Health Care
Documentation Requirements
Article III, 9 (a) (4)
 Applicable for adding a spouse, and dependent children and/or
stepchildren:
– The primary enrollee is required to provide documentation
necessary to substantiate the eligibility within 60 days of calling
the GM Benefits & Services Center, otherwise the dependent loses
coverage
– If documentation is later provided, coverage in such cases will be
reinstated retro to date the dependent was originally enrolled
(maximum 1 year) following receipt of all required documentation
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Health Care
Documentation Requirements
 Documentation Requirements in Legal Guardianship cases must
establish blood relationship, residency, and student status if the
child is between the ages of 19 and 24
 Legal Documents establishing guardianship must be provided
 Health Care coverage is effective the date the guardianship
becomes final as provided in the Legal documents, however, a
retroactive effective date is limited to 12 months
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Health Care
Documentation Requirements
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Documentation Requirements for Same-Sex Domestic Partners and their
eligible children must include:
– Signed and notarized Affidavit of a same-sex domestic partnership (applicable
to partner only);
– Proof of joint ownership (applicable to partner only);
– Proof of joint residency (applicable to partner and child);
– Proof of full-time student status, if child is between the ages of 19 and 24
(applicable to child only)
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Health Care coverage is effective the first of the month following receipt of
all appropriate documentation by the GM Benefits & Services Center
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Health Care
Dependent Enrollment Process
 The Primary enrollee either calls the GM Benefits & Services
Center or goes online to initiate adding an eligible dependent
 The Enrollee is mailed an “Hourly Dependent Enrollment
Document Request Form”, the form:
– specifies required documents for each dependent type
– advises the enrollee to complete the top portion, mail documents
with completed form to GM Benefits & Service Center within 60
days to avoid loss of coverage
– provides address and fax number, however, mail is the preferred
method
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Health Care
Dependent Enrollment Process
 If documentation is not received in 30 days, a reminder letter is
mailed to the enrollee
 If documentation is not received after 60 days after initial
notification, the enrollee is mailed a letter indicating that the
dependent(s) have been dropped from coverage, and can only
be reinstated the first of the month following receipt of proper
documentation
– If documentation is later provided, coverage in such cases will be
reinstated retro to date the dependent was originally enrolled
(maximum 1 year) following receipt of all required documentation
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Health Care
Dependent Enrollment Process
 Additional notes relative to adding a Legal Guardianship Dependent,
Same-Sex Domestic Partner, or dependent child of a domestic partner:
– Primary enrollee must call the GM Benefits & Service Center, enrollment
cannot be done online for these types of dependents;
– For a Same-Sex Domestic Partner:
• The enrollee is mailed the “Domestic Partner Enrollment Document Request
Form”, which must be completed and returned with the appropriate
documentation prior to coverage commencing
• Legal Guardianships and children of same-sex dependents between the ages of 19
and 24 are audited each year beginning in February and have until end of August
to provide proof of full time student status, or are terminated from coverage.
Coverage can be reinstated the month following receipt of documentation
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Health Care
True or False?
Traditional, Entry Level and Flex employees’
Medical Plan coverage will become effective
on the 91st calendar day?
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Health Care
Because of PPACA regulations, at
what age does a dependent child
(by birth or legal adoption) of a
primary active enrollee or their
spouse, generally lose eligibility
for GM Health Care coverage?
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Health Care
Health Maintenance Organizations (HMOs)
Overview
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Flex
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Health Care
Current HMO Carriers
HMO
Location
BCN
Flint, Lansing & Southeastern Michigan
HAP
Southeastern Michigan
Health Plus
Flint, Lansing & Saginaw
MercyCare
Wisconsin
 There are approximately 7,300 Traditional employees enrolled in
HMOs
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Health Care
HMOs
 GM is the Plan Sponsor of these Plans and NOT the
Administrator
 These are fully-insured plans and the HMO has control over Plan
Design, Case Management, Prescription Drugs, Appeals and
Mental Health Benefits
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Health Care
Appendix A
Hospital, Surgical, Medical Coverages
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Health Care
Medical Plan Comparisons
Plan Element*
Traditional Plan
Entry Level Plan
Flex Plan
Deductible (In Network)
N/A
$300/$600
$300/$600
Out of Pocket Max (In Network)
N/A
$1,000/$2,000
$1,000/$2,000
Co-insurance (In Network)
N/A
10% after deductible is met
10% after deductible is met
Office Visit Co-pay
$25
$25
100% of visit
ER Co-pay
$100
Subject to Deductible/OOPM
Subject to Deductible/OOPM
Urgent Care Co-Pay
$50
Subject to Deductible/OOPM
Subject to Deductible/OOPM
FSA
N/A
$300/$600
N/A
* Plan Element is defined in the General Definitions
Document located in the back of your binder
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Entry Level ___
Flex
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Health Care
Network Status
Provider Network
Status
Network Provider
Traditional Plan
Full Benefits for Covered
Services
Non-Network Provider
Deductible (Single/Family)
Non-Network Provider
Provisions
$250/$500
Entry Level Plan
Full Benefits for Covered
Services
$1,200/$2,100
Flex Plan
Full Benefits for Covered
Services
$1,200/$2,100
• Office Visits not covered
• Office Visits not covered
• Office Visits not covered
• 90% of Network Allowed Amount
• After the deductible has been
satisfied, covered services will be
limited to 65% of the network
allowed amount
• After the deductible has been
satisfied covered services will be
limited to 65% of the network
allowed amount
• Amounts above network allowed
amount are the responsibility of
the enrollee. Amounts do not
count toward the non-network
deductible
• Amounts above network allowed
amount are the responsibility of
the enrollee. Amounts do not
count toward the non-network
deductible
• There is no out-of-pocket
maximum limitation
• There is no out-of-pocket
maximum limitation
• Amounts above network allowed
amount are the responsibility of
the enrollee. Amounts do not
count toward the out-of-pocket
maximum
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Health Care
Conditions of Payment
Appendix A, II. A.
 Service must be prescribed by a physician, and approved by the
carrier
 Enrollee must have benefit period days available, where
applicable (described on next slide)
 Care must be medically necessary
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Health Care
Benefit Period Provisions
Appendix A, II. B.
Facility/Coverage
Benefit Period
Hospital Inpatient
365 Days
Skilled Nursing Facility
730 Days (2 days for each
remaining inpatient day)
Home Health Care
3 visits for each remaining
inpatient day
Hospice
365 Days lifetime maximum*
* May be extended beyond 365 days if the enrollee obtains
authorization from the carrier’s case management program
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Benefit period days refer
to the number of days an
enrollee is covered for
inpatient services for each
continuous period of
confinement. For each
day an enrollee is
confined, the number of
covered skilled nursing
facility days and home
health care days is
reduced as described in
the chart. After a 60 day
period of non confinement the benefit
period resets to 365 days.
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Health Care
Inpatient Hospital Coverage
Appendix A, III. A.
 Services generally covered include:
– Semiprivate room
– General nursing services
– Ancillary hospital services
 Services generally NOT covered include:
– Private room
– Incidentals (telephone, television charges)
– Admission for observation, dental surgery, or diagnostic physical
therapy
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Health Care
Outpatient Hospital Coverage
Appendix A, III. A. 3
 Coverage for hospital outpatient services are generally the same
as for inpatient coverage
 Examples of services NOT covered:
– Prescription Drugs – when not used in connection with other
outpatient services
– Coverage generally does not include treatment of chronic
conditions
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Health Care
Outpatient Hospital Coverage
Appendix A, III. A. 3.
 Emergency Room (ER)
– ER services are covered for the initial examination and treatment of
conditions resulting from accidental injury or medical emergencies
– $100 Co-payment for Traditional Plan
– Co-payment is waived if patient is admitted
 Urgent Care Centers
– $50 Co-payment per visits (Traditional Plan)
– Co-payment is waived when directly transferred from urgent care to
ER
– Facility charges are not covered by the Plan
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Health Care
Hospital Coverage Limitations and Exclusions
Appendix A, III. B.
 Coverage does NOT include:
– Services not medically necessary
– Hospital services for domiciliary, custodial, convalescent, nursing
home, or rest care
– Inpatient admissions primarily for observation, diagnostic
evaluations, inpatient physical therapy, x-ray examinations or
laboratory examinations
– Facility charges for care received in a non-approved freestanding
ambulatory surgery center
– Facility charges for immunizations
– Clinic visits
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Health Care
Skilled Nursing Facility
Appendix A, III. B.
 Services generally covered include:
– Semiprivate room
– General nursing services
– Ancillary services (laboratory exams, drugs, and medical supplies)
 Services generally NOT covered include:
– Custodial
– Domiciliary or home services
– Care of tuberculosis
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Flex
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Health Care
Occupational and Speech Therapy (OT/ST)
Appendix A, III. C.
 Services covered where expectations that therapy will improve
the condition in a reasonable and predictable period of time
 Benefit Maximums
– Therapy available while admitted to a hospital or skilled nursing
facility
– Sixty (60) total outpatient visits per condition per calendar year
– Out of network services subject to out of network cost share if
applicable
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Health Care
Outpatient Physical Therapy (PT)
Appendix A, III. C.
 Administered by TheraMatrix
– Effective July 1, 2013 – Nationwide
 In-Network
– Included in a combined total of sixty (60) covered outpatient
physical, occupational and/or speech therapy visits per condition
in any calendar year
– Enrollee’s will receive covered services with no out-of-pocket costs
if they choose a TheraMatrix provider (after any applicable cost
share requirements are met)
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Health Care
Outpatient Physical Therapy (PT)
 Out-Of-Network
– Services that are obtained from providers who are not in the
TheraMatrix network are not covered
– If there are no TheraMatrix network providers within 25 miles of an
enrollee’s home, TheraMatrix will attempt to locate a provider and
reimburse expenses
• TheraMatrix must be contacted prior to services being rendered
by a non-network provider in order to be reimbursed
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Health Care
Home Health Care Coverage
Appendix A, III. D.
 Services generally covered include:
– General nursing services
– Social service guidance, dietary guidance, and functional
occupational therapy
– Certain part-time health aide services
– Ancillary services (laboratory tests, drugs, medical supplies) when
provided and billed by an approved provider
– IV infusion therapy services subject to provisions of Appendix
A,III.D.2.(4).C.
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Flex
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Health Care
Home Health Care Coverage
Appendix A, III. D.
 Services generally NOT covered include:
– Supplies such as personal comfort items or equipment and
appliances
– Physician services, or private duty nursing
– Housekeeping services
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Flex
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Health Care
Surgical and Medical Coverage
Appendix A, III. E. – Covered Services
 Surgery (generally accepted operating and cutting procedures)
 Human organ or tissue transplants
 Hemodialysis services (when preformed in facility meeting
program standards and approved by carrier)
 Anesthesia services
 Technical surgical assistance
 Maternity care
 Medical care in hospitals
 Medical care in skilled nursing facilities
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Health Care
Surgical and Medical Coverage
Appendix A, III. E. – Covered Services
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
Consultations
Emergency treatments
Chemotherapy
Therapeutic and diagnostic radiology
Diagnostic laboratory, pathology, and other services
Preventive services
Immunizations and Vaccinations not considered preventive
Physician office visits, subject to Program provisions and
limitations
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Flex
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Health Care
Surgical and Medical Coverage
Appendix A, III. E. – Preventive Services
 When rendered by network providers they are exempt from
deductibles, co-payments or coinsurance
 They may be subject to frequency limitations and age-related
windows
 Covered services included listed in attachment labeled
“Preventive Services”
− Newly added in 2014 – Antepartum Care, BRCA Screening,
Counseling for Contraceptives
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Flex
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Health Care
Office Visits
Appendix A, III. E.
Traditional Plan
• $25 Co-payment
• In Network Only
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Entry Level Plan
• $25 Co-payment
• Does not apply to the
deductible or out-of-pocket
maximum
Flex Plan
• 100% Co-insurance
• In Network Only
• Does not apply to the
deductible or out-of-pocket
maximum
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Health Care
Ambulance Coverage
Appendix A, III. F.
 Emergency transportation
– One-way from the scene of the emergency incident
– One-way or round trip from the home to the nearest available
qualified facility
• Round trip only for homebound patients
 Transfer from one hospital to another to obtain care or services
not available at the first hospital
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Health Care
Ambulance Coverage
 Transport of inpatient hospital patient to non-hospital facility for
covered CAT scan, MRI or PET scan
– When the following conditions are met:
• Services are not available in the hospital in which the enrollee is
confined or in a closer local hospital
• The facility of transfer meets Program standards for providing services
 Air and boat ambulance services
– Only available when ground ambulance or other means of
transportation could not be used without endangering the patient’s
health
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Entry Level ___
Flex
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Health Care
Durable Medical Equipment (DME) and
Prosthetic & Orthotic Appliances
Appendix A, III. I.
 January 1, 2014, BCBSM began administering the DME benefit
 Services generally covered include:
– Purchase of DME prosthetic appliances or orthotic appliances
– Rental of durable medical equipment
– For complete list of covered items please reference App.A.III.I.3.b.(5)
 Services generally NOT covered include:
– Comfort and convenience items
– Physician’s equipment, exercise and hygienic equipment
– Dental appliances
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Flex
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Health Care
Hospice Coverage
Appendix A, III. J.
 Pre-Hospice Care
– Includes evaluation, consultation, education and support services,
concurrent with curative treatment
– Lifetime maximum of 28 pre-hospice visits (visits do not count
against Hospice lifetime maximum)
 Hospice Care
– Services for terminally ill enrollees who have a life expectancy of
twelve (12) months or less
– Lifetime maximum of 365 days (can be extended through case
management)
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Health Care
Case Management Program
Appendix A, III. K.
 Provide support for complex medical conditions, multiple
chronic conditions, or injuries & illnesses with serious, longterm effects
– Case management can help by:
• Helping the enrollee understand treatment options
• Coordinating and supporting care
• Identifying lower cost care alternative
• Provide high quality, cost-effective alternative treatment options for
patients with catastrophic, chronic, and long-term treatment needs
which may result in exhaustion of benefits or high costs
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Flex
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Health Care
Case Management Program
Appendix A, III. K.
 Conditions when Case Management may be appropriate:
– Organ transplants, Major head trauma, Spinal cord injury, Stroke,
Cancer, Newborns with high risk complications, Severe burns and
Acquired Immune Deficiency Syndrome
 General Limitations and Exclusions
–
–
–
–
Blood storage and preservation
Private duty nursing services
Research or experimental services
Services not related to specific diagnosed illness or injury
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Flex
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Health Care
Integrated Health Management (IHM)
 BlueHealthConnection (BCBSM) & ConditionCare (Anthem) are
Programs that offer support and resources if an enrollee has
complex care needs, or multiple chronic conditions including:
− Asthma, Diabetes, Chronic obstructive pulmonary disease,
Congestive heart failure, Coronary artery disease
 If a nurse calls, say “YES!”
− If selected for the program, the enrollee receives an introduction
letter, followed by a telephone call from a RN case manager
− Enrollees are welcome to call to participate
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Flex
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Health Care
Integrated Health Management
24-hour nurse line available seven days a week
 Registered nurse health coaches are ready to answer health
care questions about:
− Symptom management - Get help assessing symptoms to
determine the level of care and medical follow-up needed
− Health information – Get answers to health care questions or
concerns
− Health decision support - Get help making decisions about
treatment options for a condition or disease
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Flex
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Health Care
Integrated Health Management
 “Quit the Nic” and other smoking cessation programs
– Provides support, information tools to quit tobacco over a 12
month period
– BCBSM Program features include:
• Unlimited telephone access to a dedicated health coach
• Personal plan for quitting
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Health Care
What are the names of the four
current HMO carriers?
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Health Care
How much is the office visit
co-pay for the Entry Level
Medical Plan?
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Health Care
Prescription Drug Coverage
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Traditional ___
Entry Level ___
Flex
___
Health Care
Prescription Drug Co-payments
Retail
Traditional
Entry Level
Flex
Generic
$6
$7.50
$7.50
Brand
$12
$15
$15
Erectile Dysfunction
$17
$15
No Coverage
Traditional
Entry Level
Flex
Generic
$12
$7.50
$7.50
Brand
$17
$15
$15
Erectile Dysfunction
$21
$15
No Coverage
Mail Order
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Traditional ___
Entry Level ___
Flex
___
Health Care
Preventative Medications with No Co-payment
NEW as
of 1/1/14
NEW as
of 1/1/15
Medication
Coverage
Aspirin
Ages 45-79 for protection of cardiovascular disease
Fluoride
Children thru age 5 for prevention of cavities
Folic Acid
Women thru age 50 who are pregnant or who are planning to
become pregnant
Iron Supplements (Ferrous Sulfate
Drops)
Children thru age 12 months old
Tobacco Cessation Products
Age 18 and older
Vitamin D Supplementation
Vitamin D - OTC product for community-dwelling adults aged 65
years or older. Vitamin D2 or D3 1,000 IU or less
Breast Cancer Prevention
(Tomaxafen/Raloxifene)
For women who have NOT been diagnosed with breast cancer,
but are at increased risk for breast cancer and at low risk for
adverse medication effects.
These medications require a doctor’s prescription and must be dispensed by a participating
retail or mail-order pharmacy
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Traditional ___
Entry Level ___
Flex
___
Health Care
Maintenance Drugs
 “Maintenance drugs” are medications taken on a long-term
basis for a variety of medical conditions
 At a retail pharmacy, maintenance drugs are covered at the
applicable 34-day co-payment for the original prescription and
two (2) refills
 Thereafter, these drugs are covered at mail-order, at the
applicable co-payment for up to a 90-day supply, or at retail at
100% co-payment of Plan costs for up to a 34-day supply
 To find out if a medication is subject to these Plan provisions,
call Express Scripts or visit their website
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Traditional ___
Entry Level ___
Flex
___
Health Care
Go to www.express-scripts.com
Enter User Name
& Password or
Set up Account if
First Time User
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Traditional ___
Entry Level ___
Flex
___
Health Care
Select Price a
medication
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Traditional ___
Entry Level ___
Flex
___
Health Care
Need to select
person on contract
Enter drug name
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Traditional ___
Entry Level ___
Flex
___
Health Care
Enter Quantity
Information
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Traditional ___
Entry Level ___
Flex
___
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74
Traditional ___
Entry Level ___
Flex
___
Health Care
Mail Order Pharmacy
 To get started with Express Scripts mail-order:
− Enrollees can mail a new prescription to Express Scripts along
with a completed mail-order form
− Providers can fax, call in or e-prescribe new prescription requests
 Providers can call Express Scripts to receive instructions for
submitting prescriptions
 For refills only: Enrollees can call Express Scripts’ automated refill
system or visit their website and select “Order Center” to initiate a
refill request
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Traditional ___
Entry Level ___
Flex
___
Health Care
Specialty Drug Retail Network – Accredo
 Specialty Drugs
– Drugs generally prescribed for patients with complex diseases, which
require specialized training for self-administration and physician
coordination prior to initiation of therapy
– Patient compliance and monitoring protocols
– Drugs tend to be high cost; significant potential for waste
– Special coverage procedures include use of identified providers, coverage
review and dispensing controls
 Accredo Health Group, Inc. – Express Scripts Specialty Pharmacy
– Provides specialty pharmacy and related services for patients with certain complex
and chronic conditions through their unique Therapeutic Resource Centers
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Traditional ___
Entry Level ___
Flex
___
Health Care
Utilization Management/RX Tools
 Prior Authorization (PA)
– A prior approval process that allows prescriptions to be filled only when
specific and predefined conditions, consistent with clinical practice
guidelines, are met
– Generally needs to be reviewed annually
 Dose Optimization
– Process in which Express Scripts contacts the prescriber about dosing
opportunity for higher strength at same total daily dose
 Step Therapy (ST)
– Requires certain drug therapies to be used prior to coverage approval
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Traditional ___
Entry Level ___
Flex
___
Health Care
Hearing Aid Coverage
 AudioNet America / SVS provides hearing coverage nationwide
–
–
–
–
Audiometric examination – covered in full, once every 36 months
Hearing aid evaluation test – covered in full, once every 36 months
Conformity Evaluation – covered in full, once every 36 months
Digital hearing aids – Mid-Level standard aids covered in full;
upgrades available at additional costs
 In-network –
– Eligible for up to two hearing aids every 36 months
– Pre-authorization is required for all services
 Out-of-network - Services are not covered
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Health Care
How much is the generic drug
copayment for Entry Level and
Flex Employees at both mail
and retail?
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Health Care
What is the name of
Express Scripts’ Specialty Drug
Pharmacy?
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Health Care
Appendix B
Mental Health and Substance Abuse Coverage
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Traditional ___
Entry Level ___
Flex
___
Health Care
Mental Health and Substance Abuse
Network Providers, Appendix B, II.







Psychiatrists (Board Certified and Licensed)
Psychologists (Ph.D, Ed.D, DMH, PsyD. , and Licensure)
Social Workers (MSW, MSSW, DSW, and Licensure)
Clinical Nurse Specialist (MA, MS, MSN, and Licensure)
Hospitals
Detoxification, Residential Care, and Outpatient Facilities
Halfway Houses
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Traditional ___
Entry Level ___
Flex
___
Health Care
Mental Health and Substance Abuse
Appendix B, II. 4-12
 Responsibilities of ValueOptions
–
–
–
–
–
UBR inquiries
Authorize/approve treatment
Coordinate mental health and outpatient substance abuse care
Authorize psychological testing
Face to face assessments for the development of substance abuse
continuing care treatment plans
– Make referrals to panel providers & aftercare
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Traditional ___
Entry Level ___
Flex
___
Health Care
Mental Health and Substance Abuse Inpatient
Care Appendix B, II. A.
Benefit Period
Traditional
Entry Level
Flex
365 continuous inpatient days renewable
after 60 days of non-treatment
365 continuous inpatient days renewable
after 60 days of non-treatment
365 continuous inpatient days renewable
after 60 days of non-treatment
Subject to Medical Deductible & Out-ofPocket Maximum
Subject to Medical Deductible & Out-ofPocket Maximum
Deductible: $300/600
OOPM: $1,000/$2,000
Deductible: $300/600
OOPM: $1,000/$2,000
Applies to & Shared with medical deductible
Applies to & Shared with medical
deductible
In Network
Deductible (Single/Family)
Covered at 100%
Out-of-Pocket Maximum
(Single/Family)
Out of Network
Deductible or Out-of-Pocket
Maximum (Single/ Family)
Out of Network
Provisions
Applies to & Shared with medical
deductible
$250/$500
• 90% of Network Allowed Amount
• Amounts above network allowed
amount are the responsibility of the
enrollee. Amounts do not count toward
the out-of-pocket maximum
$1,200/$2,100
• After the deductible has been satisfied,
covered services will be limited to 65% of
the network allowed amount
• After the deductible has been satisfied
covered services will be limited to 65%
of the network allowed amount
• Amounts above network allowed amount
are the responsibility of the enrollee.
Amounts do not count toward the nonnetwork deductible
• There is no out-of-pocket maximum
limitation
• There is no out-of-pocket maximum
limitation
2014 Joint Benefit Plans Conference
$1,200/$2,100
• Amounts above network allowed
amount are the responsibility of the
enrollee. Amounts do not count toward
the non-network deductible
84
Traditional ___
Entry Level ___
Flex
___
Health Care
Mental Health and Substance Abuse
Outpatient Care (In Network)
Appendix B, II. E.
Traditional
Entry Level
Flex
Visits 1-20
Covered @ 100%
Covered @ 100%
Covered @ 100%
Visits 21-35
Covered @ 75%
Covered @ 75%
Covered @ 75%
Mental Health
(max $25 enrollee cost)
(max $25 enrollee cost)
Covered with
$25 copayment
Covered with
$25 copayment
Covered with
100% co-insurance
Visits 1-35
Covered @ 100%
Covered @ 100%
Covered @ 100%
Visits 36+
Covered with
$25 copayment
Covered with
$25 copayment
Covered with
100% co-insurance
Visits 36+
Substance Abuse
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Health Care
Appendix C
Dental Coverage
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Traditional ___
Entry Level ___
Flex
___
Health Care
Dental Coverage - Background
 Dental Plan of Michigan is the nationwide carrier of the Dental
Plan
– Enrollees have a choice of two networks:
• Delta Dental PPO
• Delta Dental Premier
• 2013 total network utilization = 94.6%
 2013 Plan Utilization:
– 73% of employees + spouses, and 67% of eligible children received
services
– Plan paid $45M for 500,000 services received
– Enrollee out-of-pocket was $13M
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Traditional ___
Entry Level ___
Flex
___
Diagnostic and Preventive Services
Health Care
PPO Dentist
Premier Dentist
Nonparticipating Dentist
Plan Pays
Plan Pays
Plan Pays
100%
100%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
70%
50%
50%
70%
50%
50%
50%
50%
50%
50%
50%
Diagnostic & Preventive
100%
Basic Services
Radiographs
Minor Restorative Services - fillings
Endodontic Services – root canals
Periodontic Services
Extractions
Oral Surgery
Major Restorative Services – crowns
100%
100%
100%
100%
100%
90%
90%
Major Services
Adjustments to Dentures – Partial or
complete
Prosthodontic Services – Used to
replace missing natural teeth (for
example, bridges and dentures).
Implants – Endosteal implants
Orthodontic Services
Orthodontic Services - braces
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60%
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Entry Level ___
Flex
___
Health Care
Covered Services
 Class I: Payable at 100% (of maximum allowed cost)
– Routine oral examinations and prophylaxes
• Not more than twice per calendar year
• Three cleanings allowed if there is a documented history of periodontal
disease, and
• Four cleanings allowed for two calendar years following periodontal
surgery
– One topical fluoride application for enrollees under age 15
– Fluoride trays for use in the delivery of topical fluoride for enrollees
undergoing radiation therapy of the head and neck due to cancer
• Payable once with the initial cancer diagnosis, and thereafter once with
each subsequent recurrence of cancer
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Entry Level ___
Flex
___
Health Care
Covered Services
 Class I: Payable at 100% (continued)
– One Brush Biopsy per calendar year for enrollees presenting with
appropriate clinical criteria or a history of behaviors placing them
at risk or oral cancer
• Covered services include the laboratory interpretation of the biopsy
specimen
– Space maintainers to replace prematurely lost posterior teeth for
children under 19 years of age
– Emergency palliative treatment
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Entry Level ___
Flex
___
Health Care
Covered Services
 Class II: Payable at 90%
– Dental x-rays, including:
• Full mouth (panoramic) - once every five consecutive calendar years,
• Bitewing x-rays - once every calendar year for enrollees age 14 and
younger; once every two years for enrollees age 15+
– Extractions
– Oral Surgery, including general anesthetics and intravenous
sedation
– Minor Restorations, including fillings
– Major Restorations
• Initial installation of crowns, or replacement of crown on the same
tooth, if at least five years have passed since the initial installation
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Entry Level ___
Flex
___
Health Care
Covered Services
 Class II: Payable at 90% (continued)
– Cosmetic Bonding
• Limited to the eight front teeth of children ages 8 through 19 years,
payable once in a consecutive three year period, when certain
conditions are presented
– One Occlusal Guard, payable once every five years
– Endodontic Treatment, including root canal therapy
– Periodontic Treatment and other diseases of the gums and tissues
of the mouth
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Traditional ___
Entry Level ___
Flex
___
Health Care
Covered Services
 Class III: Payable at 50%
– Initial Installation of Fixed Bridgework
– Initial Installation or Replacement of Partial or Full Removable
Dentures
– Endosteal Single Tooth Implant
• IV sedation and/or general anesthesia, bone grafts or specialized
implant surgical techniques are NOT covered
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Traditional ___
Entry Level ___
Flex
___
Health Care
Dental Plan Maximum Benefits
 Annual Maximum:
– $1,850 per eligible enrollee
 Lifetime Orthodontia Maximum:
– $2,200 per eligible enrollee under the age of 19
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Entry Level ___
Flex
___
Health Care
Predetermination of Services
 When a course of treatment that is expected to be greater than
$200 in cost:
– Request an estimate from Delta Dental prior to the commencement
of treatment
– Delta Dental will notify the enrollee and provider of the Plan
payable amount, and provide alternative treatment options, if
appropriate
 Predetermination is not applicable to emergency treatment,
routine oral exams and cleanings, fluoride treatments and x-rays
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Traditional ___
Entry Level ___
Flex
___
Health Care
Accidental Dental Injury
 Involves repair of sound natural teeth as a result of sudden,
unexpected impact to the outside of the mouth
– Services provided under this provision are exempt from the annual
benefit maximum and the lifetime orthodontic maximum
– Regular co-payments apply
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Traditional ___
Entry Level ___
Flex
___
Health Care
Savings Advantage of Delta Preferred Network
Comprehensive Orthodontics
Delta Dental Premier Delta Dental PPO Savings
Charge
Amount Allowed
Payment %
Delta Pays
Patient Pays
$5,250
$5,250
50%
$2,200*
$3,050
$5,250
$4,635
60%
$2,200*
$2,435
$615
* Benefits limited to lifetime $2,200 orthodontia maximum for course of treatment
completed during 2014
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Entry Level ___
Flex
___
Health Care
Appendix D
Vision Coverage
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Traditional ___
Entry Level ___
Flex
___
Health Care
Vision Plan
 Davis Vision is the nationwide carrier for the Vision Plan
 2013 Plan Utilization:
– 40% of employees and their eligible dependents received services
 Total Plan Spend:
– Total 2013 Plan spend was $3M
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Traditional ___
Entry Level ___
Flex
___
Health Care
Covered Services:
 Routine Examination, including refraction, is paid once per
calendar year:
– Network: 100% Plan paid, when performed by Optometrist or
Ophthalmologist
– Out-of-Network: Enrollee reimbursement is $37 when performed by
an Optometrist, the reimbursement when performed by an
Ophthalmologist reimbursement is based on Reasonable &
Customary (R&C) cost minus $7 co-pay
• Exception: When an exam is performed by an Ophthalmologist within
60 days of an examination by an Optometrist. The exam is based upon
referral by the Optometrist
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Traditional ___
Entry Level ___
Flex
___
Health Care
Covered Services:
 Frames
– Benefit is available once every 24 consecutive months:
• Network: $80 allowance. If frames are over $80, the Plan pays up to $24
• Out-of-Network: Enrollee reimbursement is $24. If out-of area, the
enrollee reimbursement is $24 minus a $10 co-pay
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Entry Level ___
Flex
___
Health Care
Covered Services:
 Lenses:
– Single Vision:
• Network: 100% Plan paid, once per calendar year
• Out-of-Network*: Enrollee reimbursed up to $30
− Bifocal and Trifocal:
• Network: 100% Plan paid, once per calendar year
• Out-of-Network*: Enrollee reimbursed up to $50
− Lenticular:
• Network: 100% Plan paid, once per calendar year
• Out-of-Network*: Enrollee reimbursed up to $90
* If out-of-area, enrollee reimbursement is based on Reasonable & Customary
(R&C) minus $10 co-pay
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Traditional ___
Entry Level ___
Flex
___
Health Care
Covered Services:
 Contact Lenses:
– Elective:
• Network: The Plan will pay up to a maximum of $80 allowance, once
per calendar year, in place of regular lenses
• Out-of-Network*: Enrollee reimbursement is $65
− Medically Necessary: When needed for conditions such as
irregular astigmatism, or irregular corneal curvature, or following
cataract surgery
• Network: 100% Plan pay, once per calendar year
• Out-of-Network*: Enrollee reimbursed R&C minus $10
* If out-of-area, enrollee reimbursement is based on R&C minus $10 co-pay
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Traditional ___
Entry Level ___
Flex
___
Health Care
Covered Services:
 Lens Options
– Shaded Tints #1 and #2:
• 100% Plan paid, all other lens options are not covered by the Plan
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Traditional ___
Entry Level ___
Flex
___
Health Care
Covered Services:
 Corrective Eye Surgery
– The surgery is performed by an Ophthalmologist
– Coverage includes related pre & post surgical professional
services, facility expense, and medically necessary supplies
– Cannot receive frame or lens benefit in same year, plus 3 additional
years
– Maximum benefit payable in 4-year period is $295
– Upon proof of payment to the ophthalmologist, Davis Vision will
reimburse the primary enrollee for covered expenses up to the
maximum benefit allowed
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Health Care
What is an example of a Class I
Dental service?
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Health Care
For eligible enrollees, what are the
benefit time restrictions for frames
under the Vision Plan?
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Health Care
UAW-GM LifeSteps Program Overview
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Health Care
LifeSteps Background and Program Goals
 LifeSteps was created to help GM employees lead a healthier
lifestyle. The program services all 78 GM facilities.
– Program Goals
• Provide information and tools to help employees improve health status
and decrease the risk for future illness and disease
• Educate and motivate employees to become active participants in
improving their health
• Leverage health plan and community health resources to support
employees’ good health and/or manage chronic disease
• Encourage employees to establish a relationship with their primary
care physician
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Health Care
LifeSteps Program Components
 Onsite Health Screenings
– To determine participants’ health risks
 Wellness Programs
– To educate participants on how to prevent and manage health risks
 Personalized Health Coaching
– To identify and achieve participants’ health goals
 LifeSteps Online
– To compel participants to read, learn and make health changes
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Health Care
Flexible Spending Accounts
Health Reimbursement Plan
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Entry Level ___
Flex
___
Health Care
Flexible Spending Account (FSA)
 Health Reimbursement Plan for Entry Level New Hires
– Purpose
• The purpose of the FSA is to reimburse employees the cost of eligible
health care expenses
– FSAs are notional, non-interest bearing accounts
– History
• The FSA for Entry Level New Hires became effective January 1, 2008
• The Plan is administered according to IRS regulations
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Entry Level ___
Flex
___
Health Care
FSA – Health for Entry Level New Hires
 Plan Administration:
– The Plan is administered by Bank of America
• Claim information is available online or by calling Bank of America’s
Call Center
– Employee eligibility information is available at gmbenefits.com or
by calling the GM Benefits and Services Center
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Entry Level ___
Flex
___
Health Care
FSA – Health for Entry Level New Hires
 Plan Eligibility:
– Employees classified as Entry Level
– Eligibility begins when the employee becomes eligible for health care
coverage
– Entry Level employees will be eligible for an annual FSA amount depending
upon their health care enrollment status:
• $300 for individual health care coverage
• $600 for two-party or family health care coverage
• $600 if an individual elects to opt-out of GM health care coverage
– Employees not eligible for health care coverage at the start of the year will
not receive credits to the FSA until eligibility commences, or is reinstated
during the year
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Traditional ___
Entry Level ___
Flex
___
Health Care
FSA – Health for Entry Level New Hires
 How the FSA Works:
– Expenses that are incurred during the Plan Year* may be submitted
at any time before April 30th of the following Plan Year
– Reimbursements for eligible health care expenses are not
considered taxable income
– “Use It Or Lose It” Rule – unused funds for the Plan Year* are
forfeited
– Payable benefits may not exceed the account balance
* Plan Year includes a “Grace Period” of January 1st – March 15th of the following
year
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Traditional ___
Entry Level ___
Flex
___
Health Care
Benefits Solutions Integrated Enrollee Portal
Accounts at a Glance
shows pertinent information
for all current and prior year
accounts, and links to
archived accounts.
Images shows items faxed in for
substantiation. Enrollees will receive
an email when this information is
received and imaged in the system.
Quick Claim
Entry is now
accessible from
the home page.
Help Tickets can be
submitted online by
enrollees and
tracked through to
resolution.
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Entry Level ___
Flex
___
Health Care
FSA – Health for Entry Level New Hires
 Access and use the FSA funds for eligible expenses
–
–
–
–
Bank of America FSA Visa Debit Card
Payments directly to the Provider
Reimbursement Requests submitted to Bank of America
Dependents must be considered an IRS classified 152 dependent to
have expenses covered
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Entry Level ___
Flex
___
Health Care
FSA – Health for Entry Level New Hires
 Using the FSA Debit Card for Payment:
– Use the debit card at the point-of-service (where accepted)
– Swipe the card to pay
– Funds automatically deducted from the account as long as:
• the account is active
• there is an available fund balance
• eligible medical expenses are incurred
• the debit card has not been suspended due to previously submitted
unsubstantiated claims
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Entry Level ___
Flex
___
Health Care
FSA – Health for Entry Level New Hires
 How to Pay the Provider:
– Use online access to the FSA for direct payment to the provider;
substantiation may be required
– Sign into the online account and complete the required information
at bankofamerica.com/benefitslogin
– Print the Receipt and Substantiation Form from the website, then
upload the completed form and return it to Bank of America
– The expense receipt can also be faxed to Bank of America
– Payment will be mailed to provider upon claim approval
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Entry Level ___
Flex
___
Health Care
FSA – Health for Entry Level New Hires
 Reimbursement Request to Bank of America:
– Mail or fax the completed “Receipt and Substantiation” form, along
with required substantiation, to Bank of America, OR
– Submit the claim online, along with a fax or scan of the
substantiation through the employee’s account, OR
– Call Bank of America’s Call Center for assistance with completing
the reimbursement form
– Upon approval of the claim, reimbursements can be directed to a
checking/savings account or the employee can receive a check in
the mail
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Entry Level ___
Flex
___
Health Care
FSA – Health for Entry Level New Hires
 Eligible expenses include:
– Deductibles and co-payments applicable to the GM Health Care
Plan
– Certain over-the-counter drugs, as long as they are prescribed by a
physician
– Dental and Vision services
– Complete listing at www.irs.gov in Publication 502
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Entry Level ___
Flex
___
Health Care
FSA – Health for Entry Level New Hires
 Ineligible expenses include:
– Premiums or contributions for health care or long term care
insurance
– Health-related home improvements, such as swimming pools, and
air conditioners
– Non-medical expenses
– Expenses paid or payable from other plans
– Expenses deducted on employee’s federal income tax return
– Expenses that would have been payable under GM Health Care
Plan if the employee had followed Plan rules
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Entry Level ___
Flex
___
Health Care
FSA – Health for Entry Level New Hires
 If an employee has any questions concerning their FSA, the first
point of contact should be BoA
 The participant can phone the Call Center or submit a question
online
 Eligibility questions should be directed to the GM Benefits &
Services Center
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Health Care
Flexible Spending Accounts
Dependent Care Reimbursement Plan
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Traditional ___
Entry Level ___
Flex
___
Health Care
FSA – Dependent Care Reimbursement Plan
 Purpose
− The purpose of the FSA – Dependent Care Reimbursement Plan is
to reimburse employees for the cost of eligible dependent care
expenses, as defined under Internal Revenue Code (IRC) 129
 Plan Administration
− The Plan is administered by Acclaris
− Claim information is available online at Acclaris or by calling the
Acclaris Call Center
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Entry Level ___
Flex
___
Health Care
FSA – Dependent Care Reimbursement Plan
 Plan Eligibility
– An employee is eligible to participate in the Plan on the first day of
the first pay period following the attainment of seniority
 Plan Enrollment & Election
– Eligible employees may enroll as a Participant in the Plan during
the annual election period, held each November, or when a
qualifying life event occurs
– Participants enrolled in the Plan may elect pre-tax payroll
deductions ranging from $48 to $5,000 annually
•
IRS establishes a maximum benefit which is currently $5,000 annually,
or $2,500 in the case of a married Participant that files a separate tax
return
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Entry Level ___
Flex
___
Health Care
FSA – Dependent Care Reimbursement Plan
 Eligible expenses that are incurred during the Plan year* may be
submitted to Acclaris at any time before April 30th of the
following Plan year
 Reimbursements for eligible dependent care expenses are not
considered taxable income
 Payable benefits may not exceed the account balance
 “Use It or Lose It” Rule – funds that the employee contributed
for the Plan Year* that are not used are forfeited
* Plan year includes a “Grace Period” of January 1st – March 15th of the
following year
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Traditional ___
Entry Level ___
Flex
___
Health Care
FSA – Dependent Care Reimbursement Plan
 Reimbursement Request to Acclaris
− Participants in the Plan can obtain reimbursement claim forms by
calling Acclaris or from their website
− One claim submission is allowed per week
− The minimum claim submission is $25, the final claim submission
at the end of the Plan Year may be less than $25
− A copy of receipts for services must be attached to the claim form
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Traditional ___
Entry Level ___
Flex
___
Health Care
FSA – Dependent Care Reimbursement Plan
 Eligible dependent care expenses include:
− Dependent Care expenses* for qualifying child or relative
− Children, generally under the age of 13, as defined under IRC
Section 152 (a) (1)
− Dependents who are mentally or physically incapable of self-care
and who share the same residence of the participant for more than
one-half of the Plan Year
* Qualified Dependent Care expenses include, but are not limited to; licensed nursery
schools / day care centers which care for seven or more children, baby-sitting either
in or out of the home while the parents are working, and home care specialists to
care for eligible disabled dependents.
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Entry Level ___
Flex
___
Health Care
FSA – Dependent Care Reimbursement Plan
 Ineligible dependent care expenses include:
− Baby-sitting services while the parents are not working
− Services provided in full-time residential institutions such as
nursing homes and homes for the disabled
− Services outside the participant’s household at a camp where the
dependent stays overnight
− Educational expenses for the first grade and beyond
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Entry Level ___
Flex
___
Health Care
FSA – Dependent Care Reimbursement Plan
 If an employee has any questions concerning their FSA, the first
point of contact should be Acclaris
 The participant can phone the Bank of America Call Center or
submit a question online
 Eligibility questions should be directed to the GM Benefits &
Services Center
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Health Care
True or False?
All UAW enrollees are eligible for the
FSA – Health
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Health Care
What is the annual maximum
pre-tax payroll deduction for the
FSA – Dependent Care
Reimbursement Plan?
(assuming joint tax filing if married)
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Health Care
Health Insurance Portability and
Accountability Act (HIPAA)
Protected Health Information (PHI)
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Entry Level ___
Flex
___
Health Care
HIPAA/PHI
 Health Insurance Portability and Accountability Act (HIPAA) is a
Federal law passed in 1996 that established standards for
sharing Protected Health Information (PHI)
 PHI is individually identifiable health information that relates to:
– the past, present or future physical or mental condition of an
Individual
– provision of health care to an Individual
– or payment for such health care
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Entry Level ___
Flex
___
Health Care
HIPAA/PHI
 Covered entities (i.e. health care plans, payers, and providers)
must maintain strict security provisions regarding the use and
disclosure of PHI
 UBRs are not covered entities
– Carriers therefore cannot share PHI with a UBR unless they have a
signed authorization
– A sample authorization is in the binder materials
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Health Care
Appeals Process
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Entry Level ___
Flex
___
Health Care
External Appeals Process
 Pursuant to the Patient Protection and Affordable Care Act
(PPACA), enrollees may pursue an external review following
receipt of adverse benefit determinations
– Conducted by Independent Review Organization (IRO)
– Effective January 1, 2012
 Applies to Traditional Plan enrollees and their eligible
dependents
– Appendices A & B (Medical, Prescription Drug, Behavioral Health)
 Applies to Traditional Employees enrolled in Dental Plan
– Appendix C
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Entry Level ___
Flex
___
Health Care
The External Review Process is not applicable to:
 Employees and their eligible dependents enrolled in the
following Plans:
−
−
−
−
−
−
Entry Level Health Care Plan*
Flex Health Care Plan*
Entry Level Dental (Appendix C)**
Vision Plan (Appendix D)***
Eligibility Appeals***
HMOs – Enrollees will continue to use the HMOs internal review
process for adverse claims
* Due to grandfathered status under PPACA
** Due to status as “fully insured”, carriers decision is final
*** Decision does not involve medical necessity
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Entry Level ___
Flex
___
Health Care
External Appeals Process
 The External Appeals Process is started if an enrollee disagrees
with an adverse benefit determination based on the Mandatory
Appeal Process (also referred to as the DOL or Department of
Labor process)
− Mandatory Appeal Process must be completed within 180 DAYS of the
initial denial
− Following receipt of the mandatory appeal denial, which will include
the information on how to request an external review, the enrollee has
FOUR MONTHS to make a request to the Carrier for an external review
− Upon receipt of the request, the Carrier will send the case to an
Independent Review Organization (IRO)
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Entry Level ___
Flex
___
Health Care
External Appeals Process
 The IRO will make a determination of the claim, based on whether
the case involves “medical judgment” based on benefit guidelines
‒ If yes, IRO will make a determination to either uphold or overturn the
carrier’s decision
‒ If no, the IRO will notify the carrier that it can not make a determination on
the matter
 The Carrier may forward all non-determination cases to GM who
will:
− Open a Voluntary Review Case for the appeal
− Send acknowledgment letter to enrollee or UBR (whoever generates the
appeal) that IRO did not make a decision and case is being referred to the
Voluntary Review process
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Entry Level ___
Flex
___
Health Care
Appeals Process for Traditional Enrollees
Appeal Process
Timeline
Time limit for enrollee/UBR/International Rep to file
“mandatory “DOL appeal after initial claim denial
180 days
Time limit for Carrier to respond to initial appeal
60 days
Time limit for enrollee/UBR/International Rep to
request an External Review with an Independent
Review Organization (IRO) if denial is upheld
4 months
Time limit for final determination from IRO
If IRO declines to make a determination, the case can
be referred to Voluntary review
GM responds to Voluntary review request
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Dependent
on case
Dependent on case
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Entry Level ___
Flex
___
Health Care
Appeals Process for Entry Level and
Flex Plan Enrollees
Appeal Process
Timeline
Time limit for enrollee/UBR/International Rep to file
“mandatory” DOL appeal after initial claim denial
180 days
Time limit for Carrier to respond to initial appeal
60 days
Enrollee/UBR requests a Voluntary review from GM if the
denial is upheld
Dependent on case
UBR can forward case to International Rep to review with the
Control Plan and/or GM Plan Administration if denial is upheld
Dependent on case
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Health Care
Assessment
 Under PPACA, an employee will be covered under the group
health care medical plan on the 91st day that they are actively at
work.
A) True
B) False
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Health Care
Assessment
 Required documents for adding a dependent to substantiate
eligibility, must be provided to the GM Benefits and Service
Center within 30 days.
A) True
B) False
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Health Care
Assessment
 Dependent Children by Legal Guardianship are covered under
PPACA in such that they are covered under group health care
medical up until age 26.
A) True
B) False
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Health Care
Assessment
 Social service guidance, dietary guidance, and functional
occupational therapy are generally services covered under
Home Health Care Coverage.
A) True
B) False
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Health Care
Assessment
 Flexible Spending Accounts – Health Reimbursement Plan are a
covered benefit for Entry Level and Flex employees.
A) True
B) False
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Health Care
Thank You
Questions?
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Health Care
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