Post on 23-Dec-2015
October 1, 2012 – December 31, 2013
Cape Coral Professional FirefightersHealth Insurance Trust
Benefit and Eligibility Information 1
Medical Plans 2
Side-by-side Comparisons 3-4
Aetna Value Adds 5
Benefit Resource Center 6
Newborns’ and Mothers’ Health Protection Act
Women’s Health And Cancer Rights Act 7
Medicare Part D 8
HIPAA Privacy 9
Important Contact Information 10
Table Of Contents
This illustration is intended to give a brief overview of benefits offered. Refer to the contract/proposal/plan document for a detailed, accurate description of benefits. This is an illustration based on estimated enrollment numbers. Final rates will be based on actual enrollment, plan design chosen and plan effective date. Every attempt has been made to accurately reflect the details of the plan, should there be any errors, the terms and conditions of the summary plan description/contract prevail.
Benefit Information
Your Benefits Plan
Cape Coral Professional Firefighters Health Insurance Trust
offers three medical benefit options for you to choose from.
The following pages will provide a basic summary of each plan
offered.
Eligibility
You are eligible to join the Trust Benefit Plan on your date of
hire.
You may also enroll your dependents in the Trust Benefit Plan
when you enroll. Eligible dependents include:
Your spouse, unless you are legally separated or
divorced;
A dependent who is 26 years of age or younger
Under the plan children include your natural children, step-
children living with you, legally adopted children and any other
children for whom you have legal guardianship.
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When Can You Enroll?You can sign up for benefits at any of the following times:
When hired as a firefighter by the City of Cape Coral Fire Department for continuous, full-time employment;
During the annual open enrollment period; Within 30 days of a qualified family-status change.
If you do not enroll at the above times, you must wait for the next annual open enrollment period.
Extended Dependent CoverageFor medical coverage only, extended coverage may be offered for dependent children up to the end of the calendar year in which your dependent reaches age 30, if they meet the following requirements:
- Unmarried and do not have dependents of their own
- Are a resident of Florida or a student, AND
- Do not have coverage as a named subscriber, enrollee, or covered person under any other group insurance policy or individual health plan or entitled to Medicare benefits.
Medical plans
About Your Medical Options
For most people, medical insurance is no longer a “want” – it’s
a need. We’ve all seen the cost of medical care skyrocket
over the years, so we need insurance to help protect not only
our physical fitness – but our financial fitness, as well.
Cape Coral Firefighters Health Insurance Trust offers you
three medical plans to choose from - all through Aetna.
Benefits will vary depending on the plan you and your family
choose.
Under the Health Network Only Plan ( HMO), members are
allowed to utilize doctors and facilities only in the Aetna Health
Network Only network. The Health Network Option Plan
(POS), provides members with the flexibility of utilizing doctors
and facilities in or out of the Aetna Network. If a member
utilizes care out-of-network, then their out-of-pocket costs will
be higher than with a participating Aetna provider. Members
are not required to choose or utilize a PCP (Primary Care
Physician), but it is recommended that you do. The third plan
is the Health Network Option (HDHP), a high deductible plan,
which also gives members the flexibility of utilizing providers
in or out of the Aetna Network.
On the following page you can compare the above mentioned
plans side-by-side. There’s sure to be a medical option that
will help you and your eligible dependents stay physically and
financially fit.
Key Benefit Terms
COBRA – A Federal law that allows workers and dependents
who lose their medical coverage to continue any of these
coverages for a specified length of time by electing and paying
for continuation benefits.
Coinsurance – The percentage of the medical charge that you
pay after the deductible has been met.
Copayment – A flat fee that you pay for medical services,
regardless of the actual amount charged by your doctor or
another provider. This generally applies to physician office
visits and prescription drugs.
Deductible – The amount you pay toward medical expenses
each calendar year before the plan begins paying benefits.
Maximum out of Pocket – The maximum amount (includes
coinsurance and deductible) that an insured will have to pay
for covered expenses under a plan. Once the out-of-pocket
maximum is reached, the plan will cover eligible expenses at
100%.
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Aetna Network
Open Access HMOHealth Network Only
Open Access POSHealth Network
Options
Open Access HDHPHealth Network
Options
In-Network Benefits
Calendar Year Deductible (Individual/Family) None/None $500/$1,000 $1,500/$3,000
Out-of-Pocket Maximum (Individual/Family) (Includes Deductible and Coinsurance )
$3,000/$6,000 (co-pays accumulate towards out-of-
pocket maximum)
$3,500 /$7,000(coinsurance and deductible
accumulate towards out-of-pocket maximum)
$5,000 /$10,000coinsurance and deductible
accumulate towards out-of-pocket maximum)
Coinsurance (Based on Contracted Rate) 100% 80% 80%
Annual Maximum Unlimited Unlimited Unlimited
Physician Services
Preventive CareRoutine Adult Physical Exam and Immunizations
Well Woman Exam
Mammograms
Colonoscopy (Routine for age 50+, then frequency schedule applies)
Well Child Care
100%, deductible does not apply
100%, deductible does not apply
100%, deductible does not apply
Office Services
Office Visits-PCP
Office Visits-Specialist Allergy Injections
$15 copay
$25 copay
100%, deductible does not apply
$15 copay
$30 copay
$20 copay
$20 copay
Inpatient & Outpatient Services
Urgent Care Centers
Emergency Room Facility Services
Provider Services at ER and Hospital
Provider Services Radiology and Anesthesiology at an Ambulatory Surgical Facility
$50 copay
$150 copay
100%, deductible does not apply
100%, deductible does not apply
$40 copay
$125 copay
80% after deductible
80% after deductible
$50 copay
$100 copay
80% after deductible
80% after deductible
Outpatient Diagnostic Services
Independent Clinical Lab
Independent Diagnostic Testing Facility
Outpatient Hospital Facility Services
Independent Advanced Imaging Facility (MRI, CAT, PET Scans)
100%, deductible does not apply
100%, deductible does not apply
100%, deductible does not apply
100%, deductible does not apply
100%, deductible does not apply
100%, deductible does not apply
100%, deductible does not apply
$125 copay
100%, deductible does not apply
100%, deductible does not apply
100%, deductible does not apply
80% after deductible
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As you can see, the plan is designed to combine in-depth coverage with cost-effective prices. This summary contains highlights only and is subject to change. The
specific terms of coverage, exclusions and limitations including legislated benefits are contained in the Summary Plan Description or Insurance Certificates. This plan is
insured and / or administered by Aetna. PLEASE NOTE THAT OUT-OF-NETWORK SERVICES ARE SUBJECT TO BALANCE BILLING.
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Aetna Network
Open Access HMOHealth Network Only
Open Access POSHealth Network
Options
Open Access HDHPHealth Network
Options
In-Network Benefits – Continued
Hospital / Surgical
Inpatient Hospital Facility
Physician, specialists and surgeon services; anesthesia, oxygen, drugs and medication
Outpatient Hospital Facility Services
Outpatient Surgical Center
$500 copay
100%, deductible does not apply
100%, deductible does not apply
100%, deductible does not apply
$600 copay
80% after deductible
80% after deductible
$200 co-pay
80% after deductible
80% after deductible
80% after deductible
80% after deductible
Other Services
Mental Health / Substance Abuse
Inpatient Hospital
Provider Services/Office Visits$500 copay
$15 copay per visit
$600 per admission deductible waived
$15 copay per visit
80% after deductible
$20 copay per visit
Out-of-Network Benefits
Deductible
Coinsurance
Out-of-Pocket Maximum
Not Available
$2,000 /$4,000
60%
$5,000 /$10,000
$3,000 /$4,000
60%
$9,000 /$18,000
Prescription Drugs
Annual Prescription Deductible
Individual / Family None / None None / None None / None
Tier 1 (Deductible waived) $10 copay $10 copay $10 copay
Tier 2 $30 copay $30 copay $30 copay
Tier 3 $50 copay $50 copay $50 copay
Mail Order 2.5 x retail copay 2.5 x retail copay 2.5 x retail copay
Bi-Monthly Employee Costs
Employee
Employee + Spouse
Employee + Child(ren)
Family
$0.00
$151.13
$83.70
$235.18
$0.00
$191.35
$106.72
$291.08
$0.00
$124.59
$68.91
$193.98
Prescription Drug Benefits at a Reduced Cost – Did you know you can obtain prescription drugs at local retailers at a reduced cost and sometimes even free? Publix offers a variety of generic Oral Antibiotic medications to you absolutely free. Bring in your prescription for an approved medication and receive it FREE, up to a 14-day supply. Publix recently approved a medication for diabetes. CVS, Target, Walgreens & WalMart also offer over 400 generic prescriptions for $4 and a 90 day supply for approx. $10 . Remember DO NOT show your Aetna ID card to receive these benefits, or you will be charged your Aetna drug rate.
Member Resources
Aetna Navigator ® Secure Member Website – Aetna Navigator is your secure member website. It’s where you go to:
Find doctors, dentists, pharmacies & hospitalsGet an ID card Look up a claimYou’re mobile. So are we.Check your coverageKeep track of health care costsIt’s personalized for you and your familyIt’s easy to get started – www.aetnanavigator.comYou can also get a summary of your doctor visits, medical tests, prescriptions and other health activities. Look up health topics. Complete a Health Assessment.
Beginning Right® Maternity Program
Helping you and your baby grow healthy – togetherYou get the Beginning Right Maternity management program with your Aetna plan.Information for a healthier pregnancy – You will get materials on – Prenatal care – Preterm labor symptoms – What to expect before/after delivery – Newborn care and moreSpecial attention for Pregnancy risksSolid support to quit smoking
Aetna Discount Programs
Gym MembershipsEyeglasses and contactsWeight-loss programs ( Jenny Craig® - Nutrisystem® - eDiets® )Chiropractic visitsMassage therapyAcupunctureHearing aids and more
Personal Health Record
Access family history detailsReview your office visits, prescriptions, conditions & treatmentsGet a health summaryDownload & share your information easily with health care providersReceive important medical alertshttp://healthyis.aetna.com/personalhealth
24-hour Nurse Line for Health Questions
1. Call a registered nurse toll-free2. Visit member site www.aetna.com3. Listen to Audio Health Library
In addition to the network of physicians, hospitals, emergency rooms, and urgent care clinics, you also have the option of going to the convenient care clinics located within some grocery and drug stores, for minor illness such as ear aches, colds, flu and so on. By selecting one of these providers, you pay only the regular office visit copay; a significant savings over the emergency room and urgent care copayments.
Please visit the various websites for locations, hours of operations and scope of services.
CVS Minute Clinic: www.cvs.com
Publix Little Clinic: www.Publix.com
Walgreen’s Take Care Clinic: www.walgreens.com
Aetna Value Adds
Frequently Asked Questions About Your Medical Plan
Q. What should I do if I have a problem getting a claim paid?
A. Start by contacting the carrier’s member services number to determine
the nature of the problem. If the issue is the way the doctor or other service
provider has billed the claim, then contact your doctor or Claims Advocate at
USI. If the insurance company has an eligibility issue, contact Human
Resources for assistance.
Q. What is the difference between brand formulary, brand non-
formulary, and generic drugs?
A. Brand formulary is a prescription drug that is listed on the formulary (i.e.,
a list of prescription drugs covered by the plan). These drugs are protected by
a patent issued to the original innovator or marketer. Brand non-formulary
drugs are patent protected but are not listed. A generic equivalent drug can
become available when the patent protection runs out, and is deemed equal in
therapeutic power to the brand name originals.
Q. When should I go the Urgent Care vs. Emergency Room?
A. For non-life threatening injury/illness after normal doctor’s office hours.
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Toll-free benefit call center available to:
• Answer questions regarding your health and other benefit plans
• Network: Is my doctor on the plan?• Plan Coverage: Does my plan cover this?• Billing: I received a bill from my provider, do I need to
pay?• Once you’ve tried, but need help understanding how a carrier
paid your claim • Specialist support to help you with complex claims issues• Medical appeals information and support• Life event (family status) rules – what changes can I make?• Life Insurance Beneficiary form requirements• How do I complete an Evidence of Insurability form and
where do I send it?• What happens if I have coverage under two different medical
plans?
Benefit Resource Center Services
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Required Annual Employee Disclosure Notices
The Newborns’ and Mothers’ Health Protection Act
of 1996
The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits
group and individual health insurance policies from restricting benefits
for any hospital length of stay for the mother or newborn child in
connection with childbirth; (1) following a normal vaginal delivery, to
less than 48 hours, and (2) following a cesarean section, to less then
96 hours. Health insurance policies may not require that a provider
obtain authorization from the health insurance plan or the issuer for
prescribing any such length of stay. Regardless of these standards an
attending health care provider may, in consultation with the mother,
discharge the mother or newborn child prior to the expiration of such
minimum length of stay.
Further, a health insurer or health maintenance organization may not:
1. Deny to the mother or newborn child eligibility, or continued
eligibility, to enroll or to renew coverage under the terms of the
plan, solely to avoid providing such length of stay coverage;
2. Provide monetary payments or rebates to mothers to encourage
such mothers to accept less than the minimum coverage;
3. Provide monetary incentives to an attending medical provider to
induce such provider to provide care inconsistent with such
length of stay coverage;
4. Require a mother to give birth in a hospital; or
5. Restrict benefits for any portion of a period within a hospital
length of stay described in this notice.
These benefits are subject to the plan’s regular deductible and co-pay.
For further details, refer to your SPD. Keep this notice for your
records and call your Trust for more information.
Women’s Health and Cancer Rights
Act of 1998
The Women’s Health and Cancer Rights Act of 1998 requires Cape
Coral Professional Firefighters to notify you, as a participant or
beneficiary of the Cape Coral Professional Firefighters, Local 2424
Health and Welfare Plan, of your rights related to benefits provided
through the plan in connection with a mastectomy. You, as a
participant or beneficiary, have rights to coverage to be provided in a
manner determined in consultation with your attending physician for:
1. All stages of reconstruction of the breast on which the
mastectomy was performed;
2. Surgery and reconstruction of the other breast to produce a
symmetrical appearance; and
3. Prostheses and treatment of physical compilations of the
mastectomy, including lymphedema.
These benefits are subject to the plan’s regular deductible and co-pay.
For further details, refer to your SPD. Keep this notice for your
records and call Human Resources for more information.
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Children’s Health Insurance Program
Reauthorization Act (CHIPRA) of 2009
Effective April 1, 2009, a special enrollment period provision is added
to comply with the requirements of the Children’s Health Insurance
Program Reauthorization Act (CHIPRA) of 2009. If you or a
dependent is covered under a Medicaid or CHIP plan and coverage is
terminated as a result of the loss of eligibility for Medicaid or CHIP
coverage, you may be able to enroll yourself and/or your
dependent(s). However, you must enroll within 60 days after the date
eligibility is lost. If you or a dependent becomes eligible for premium
assistance under an applicable State Medicaid or CHIP plan to
purchase coverage under the group health plan, you may be able to
enroll yourself and/or your dependent(s). However, you must enroll
within 60 days after you or your dependent is determined to be eligible
for State premium assistance. Please note that premium assistance is
not available in all states.
Section 111
Effective January 1, 2009 group health plans are required by Federal
government to comply with Section 111 of the Medicare, Medicaid, and
SCHIPExtensions of 2007’s new Medicare Secondary Payer
regulations. The mandate is designed to assist in establishing
financial liability of claims assignments. In other words, it will help
establish who pays first. The mandate requires group health plans to
collect additional information, more specifically Social Security
numbers for all enrollees, including dependents 6 months of age or
older. Please be prepared to provide this information on your benefits
enrollment form when enrolling into benefits.
Required Annual Employee Disclosure Notices
Medicare Part DThis notice applies to employees and covered dependents who are
eligible for Medicare Part D.
Please read this notice carefully and keep it where you can find it.
This notice has information about your current prescription drug
coverage with Cape Coral Firefighters Local 2424, and prescription
drug coverage available for people with Medicare. It also explains the
options you have under Medicare prescription drug coverage and can
help you decide whether or not you want to enroll. At the end of this
notice is information about where you can get help to make decisions
about your prescription drug coverage.
Medicare prescription drug coverage became available in 2006
to everyone with Medicare through Medicare prescription drug
plans and Medicare Advantage Plans that offer prescription drug
coverage. All Medicare prescription drug plans provide at least a
standard level of coverage set by Medicare. Some plans may
also offer more coverage for a higher monthly premium.
Because your existing coverage is on average at least as good as
standard Medicare prescription drug coverage, you can keep this
coverage and not pay extra if you later decide to enroll in
Medicare prescription drug coverage.
Individuals can enroll in a Medicare prescription drug plan when they
first become eligible for Medicare and each year from October 15th
through December 7th. Beneficiaries leaving employer/union
coverage may be eligible for a Special Enrollment Period to sign up for
a Medicare prescription drug plan.
You should compare your current coverage, including which drugs are
covered, with the coverage and cost of the plans offering Medicare
prescription drug coverage in your area.
If you do decide to enroll in a Medicare prescription drug plan
and drop your Cape Coral Professional Firefighters, Local 2424
prescription drug coverage, be aware that you and your
dependents may be able to get this coverage back. Please
contact us for more information about what happens to your
coverage if you enroll in a Medicare prescription drug plan.
You should also know that if you drop or lose your coverage with Cape
Coral Firefighters, Local 2424 and don’t enroll in Medicare prescription
drug coverage after your current coverage ends, you may pay more
(a penalty) to enroll in Medicare prescription drug coverage later.
If you go 63 days or longer without prescription drug coverage that’s at
least as good as Medicare’s prescription drug coverage, your monthly
premium will go up at least 1% per month for every month that you did
not have that coverage. For example, if you go nineteen months
without coverage, your premium will always be at least 19% higher
than what many other people pay. You’ll have to pay this higher
premium as long as you have Medicare prescription drug coverage. In
addition, you may have to wait until the following November to enroll.
For more information about this notice or your current
prescription drug coverage…
Contact our office for further information (see contact information
below). NOTE: You will receive this notice annually and at other times
in the future such as before the next period you can enroll in Medicare
prescription drug coverage, and if this coverage through Cape Coral
Professional Firefighters, Local 2424 changes. You also may request
a copy.
For more information about your options under Medicare
prescription drug coverage…
More detailed information about Medicare plans that offer prescription
drug coverage is in the “Medicare & You” handbook. You’ll get a copy
of the handbook in the mail every year from Medicare. You may also
be contacted directly by Medicare prescription drug plans. For more
information about Medicare prescription drug plans:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see your
copy of the Medicare & You handbook for their telephone
number) for personalized help,
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call
1-877-486-2048.
For people with limited income and resources, extra help paying for
Medicare prescription drug coverage is available. Information about
this extra help is available from the Social Security Administration
(SSA) online at www.socialsecurity.gov, or you call them at 1-800-
772-1213 (TTY 1-800-325-0778).
Remember: Keep this notice. If you enroll in one of the new
plans approved by Medicare which offer prescription drug
coverage, you may be required to provide a copy of this notice
when you join to show that you are not required to pay a higher
premium amount.
Name of Entity/Sender: Cape Coral Professional Firefighters,
Local 2424
Contact--Position/Office: Sharon Thompson (239) 458-2424
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Required Annual Employee Disclosure Notices continued
I. No access to protected health information (PHI)
except for summary health information for limited
purpose and enrollment / dis-enrollment information.
Neither the group health plan nor the plan sponsor (or any
member of the plan sponsor’s workforce) shall create or
receive protected health information (PHI) as defined in
45 C.F.R. §160.103 except for (1) summary health
information for purpose of (a) obtaining premium bids or
(b) modifying, amending, or terminating the group health
plan, and (2) enrollment and dis-enrollment information.
II. Insurer for group health plan will provide privacy
notice
The insurer for the group health plan will provide the
group health plan’s notice of privacy practices and will
satisfy the other requirements under HIPAA related to the
group health plan’s PHI. The notice of privacy practices
will notify participants of the potential disclosure of
summary health information and enrollment / dis-
enrollment information to the group health plan and the
plan sponsor.
III. No intimidating or retaliatory acts
The group health plan shall not intimidate, threaten,
coerce, discriminate against, or take other retaliatory
action against individuals for exercising their rights , filing
a complaint, participating in an investigation, or opposing
any improper practice under HIPAAA.
IV. No Waiver
The group health plan shall not require an individual to
waive his or her privacy rights under HIPAA as a
condition of treatment, payment, enrollment or eligibility.
If such an action should occur by one of the plan
sponsor’s employees, the action shall not be attributed
to the group health plan.
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HIPAA Privacy Policy for Fully Insured Plans with no Access to PHI
The group health plan is a fully insured group health plan sponsored by the “Plan Sponsor”. The group health plan and the plan sponsor intend to comply with the requirements of 45 C.F.R. §164.530 (k) so that the group health plan is not subject to most
of HIPAA’s privacy requirements.
Michelle’s Law
The law allows for continued coverage for dependent children who are
covered under your group health plan as a student if they lose their
student status because of a medically necessary leave of absence
from school. This law applies to medically necessary leaves of
absence that begin on or after January 1, 2010.
If your child is no longer a student, as defined in your Certificate of
Coverage, because he or she is on a medically necessary leave of
absence, your child may continue to be covered under the plan for up to
one year from the beginning of the leave of absence. This continued
coverage applies if your child was (1) covered under the plan and (2)
enrolled as at student at a post-secondary educational institution
(includes colleges, universities, some trade schools and certain other
post-secondary institutions).
Your employer will require a written certification from the child’s
physician that states that the child is suffering from a serious illness or
injury and that the leave of absence is medically necessary.
Patient Protection:
If the Group Health Plan generally requires the designation of a primary
care provider who participates in the network and who is available to
accept you or your family members. For children, your may designate a
pediatrician as the primary care provider.
You do not need prior authorization from the carrier or from any other
person (including a primary care provider) in order to obtain access to
obstetrical or gynecological care from a health care professional in the
network who specializes in obstetrics or gynecology. The health care
professionals, however, may be required to comply with certain
procedures, including obtaining prior authorization for certain services,
following a pre-approved treatment plan or procedures for making
referrals.
For a list of participating health care professionals who specialize in
obstetrics or gynecology, or for information on how to select a primary
care provider, and for a list of the participating primary care providers,
contact the Plan Administrator or refer to the carrier website.
It is your responsibility to ensure that the information provided on your
application is accurate and complete. Any omissions or incorrect
statements made by you on your application may invalidate your
coverage. The carrier has the right to rescind coverage on the basis of
fraud or misrepresentation.
Important Contact Information
Carrier/Vendor Plan Phone Number Website
Aetna Medical 800-370-4526 www.aetnacom
Benefit Resource
CenterAdvocacy Assistance 855-674-6699 BRCEast@usi.biz
USI –
Wanda Champagne
Medical, Rx and Health
Advocate954.-607-4127 Wanda.champagne@usi.biz
If you have questions about any of the benefits or services described in this Guide, please contact the
carrier or vendor that handles the plan administration. Toll-free customer service telephone numbers and
websites are listed below for your reference.
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Notes
Notes