Gig Harbor Firefighters Union Health and Welfare Trust ... · This Benefits Guide is meant to be an...

Gig Harbor Fire | 2019 Benefits | 1

Gig Harbor Firefighters Union Health and Welfare Trust

Benefits Guide


This Benefits Guide is meant to be an aid to help you better understand the Gig Harbor Firefighters Union Health & Welfare Trust (the Trust) benefits package and how to utilize it when you need to.Gig Harbor Firefighters Union Health & Welfare Trust has retained the services of LBG Advisors, LLC to help design the plan and assist employees in understanding how to use the plan.This booklet will briefly highlight the major points of the benefit plan Gig Harbor Firefighters Union Health & Welfare Trustsponsors and it is not intended to replace your detailed insurance contract or other insurance provider coverage booklets.The information is provided for informative, illustrative and comparative purposes only and should be used for ‘casual’ reference. Your actual benefits are subject to the terms and conditions of each insurance carrier’s actual contract.We at LBG Advisors, LLC are here for you and your dependents and available to answer any questions you may have regarding your benefits and coverage.

Please do not hesitate to contact us and use our services if you have need.

What’s Inside?

X Healthcare Definitions X Changing Your BenefitsX How Your Plan WorksX HealthJoy- New Benefits AppX Cypress Benefit- Plan AdministratorsX AMPS- Cost Containment ServicesX AMPS- Care Connex X Magellan Rx- Pharmacy Benefit ManagerX Delta DentalX Life & LTDX NueSynergy- HRAX Regenexx Stem Cell TherapyX Coordination of BenefitsX LBG Advisors- Health Benefits Broker X Required Notices


Healthcare Definitions

Preventive Care Services – These are services that

are generally linked to routine wellness exams and

screenings. Non-preventive services are those that

are considered treatment or diagnosis for an illness,

injury, or other medical condition. Preventive care is

covered at 100% in-network.

Annual Deductible – The amount of money you

must first pay out of pocket before your plan begins

paying for services covered by coinsurance.

Coinsurance - the percentage of covered expenses

shared by you and the plan. In most cases,

coinsurance is paid after you meet a deductible.

For example, the Basic Plan pays 80% of the covered

charge after your Annual Deductible (if applicable).

You are responsible for paying the remaining 20%

coinsurance and any of the deductible that may

apply to the claim.

Copayments and Coinsurance – A copayment (or

copay) is the fixed dollar amount you pay at the time

of service. In some cases, you may be responsible for

coinsurance after the copay is made.

Maximum Out of Pocket Amount – Your plan

provides a stated maximum annual cost for you and

your covered dependents. It includes amounts you

pay for your deductible, coinsurance, pharmacy and

co-payments. Once you reach this limit, your plan

covers 100% of your eligible claims expenses for the

rest of the year.

Physician Only Services (Network)- Claims that are

paid to individual providers or non hospital or facility

based groups.

Reference Based Pricing (RBR)- All hospital, facility

and non network claims are paid using RBR which

could result in a balanced bill to the patient. See

AMPs info.


Healthcare Definitions continued

Summary Plan Description (SPD) – The SPD is an

important document that defines the terms and care

offered by the medical plan. The booklet describes

who is eligible and when coverage terminates. It

offers definitions for important terminology found

within the contract to help you better understand

the coverage afforded by the plan design. The

Summary Plan Description also provides a list of

specifically excluded services, procedures and

conditions as well as describing your rights to appeal

decisions that you disagree with.

Health Plans are legally obligated by The Employee

Retirement Income Security Act (ERISA) to provide

participants SPDs for each benefit plan offered by the

health plan. The most current SPD is available on the

Trust web site

www.gigharborfirebenefits.weebly.com

http://www.gigharborfirebenefits.weebly.com/


Changing Your Benefits

Certain Qualified Life Events (QLEs) may enable you to change your benefit elections at a time other than during open

enrollment. You can change your benefit elections during the year if you experience a qualified life event. QLEs include:

Marriage

Divorce, annulment, or legal separation

Birth of your child

Death of your spouse or dependent child

Adoption of/placement for adoption of your child

Termination or commencement of your

spouse’s employment

Change of employment status by you or your spouse,

or another dependent

A significant change in your or your spouse’s health

coverage due to your spouse’s employment

Qualification by the Plan Administrator of a Medical

Child Support Order

Entitlement to Medicare or Medicaid

Dependent satisfies or ceases to satisfy

eligibility requirements

Commencement of or return from an unpaid

leave of absence

A change in the place of residence of you, your

spouse, or your dependent

Your dependent satisfies or ceases to satisfy eligibility

requireements

Notify the Trust and Cypress Benefits of any change

in address as soon as possible to avoid missing

communications.


How Your Plan Works

Health & Welfare Trust

Medical Cost Containment Prescription Benefit Manager

Medical Administrator

Phcs Provider only network.

Heartsmart provider only network.


HealthJoy- Your New Benefits App

Further details are included on the health benefits website under the “HealthJoy” tab, at:www.gigharborfirebenefits.weebly.com



Cypress Benefit Administrators is the hub of your plan. They administer the medical benefits and can help with benefit questions and provide claims advocacy.

Providers and facilities will work with Cypress and AMPS for payment of claims costs. PHCS and Heartsmart are physician only networks.

Further details are included on the health benefits website:www.gigharborfirebenefits.weebly.com

Customer service and inquiries:Brandi Pierce

Phone (855) 351-0582 or (971) 600-3520

[email protected] / Changes

Erin MaurerPhone 877-236-0844

Cypress Benefits- Medical Administrator


tel:(855) 351-0582

tel:(971) 600-3520

mailto:[email protected]


Medical Benefits Summary- Actives

Benefits Summary

Participant- Active

Deductible per Plan Year*

$500 Covered Person

$1,000 Family

Total Out of Pocket Limit$3,000 Individual

$6,000 Family

Covered Services Benefit

Preventative CareNo charge; deductible does

not apply

Primary Care Visit$20 copay/office visit;

Deductible does not apply

Diagnostic Test

(x-ray, blood work)

Physicians office: $20 copay,

deductible does not apply

Emergency Room Services

Emergency medical

condition 20% coinsurance

after $200 copay

Urgent Care$20 copay/office visit;


Through Care Connex with AMPS and the PHCS network, all providers are in network*All facility/hospital claims are priced through AMPS.*Before services are rendered, verify that it does not require authorization.* Maximum annual out of pocket total is the combined deductible plus the coinsurance.** The coinsurance applies after the deductible has been reached.*** Copays accumulate toward coinsurance limits.


Medical Benefits Summary- Retiree

Benefits Summary

Participant- Retiree

Deductible per Plan Year*

$1,500 Individual

$3,000 Family

Total Out of Pocket Limit$4,000 Individual

$8,000 Family

Covered Services Benefit

Preventative CareNo charge; deductible does

not apply

Primary Care Visit$20 copay/office visit;

Deductible does not apply

Diagnostic Test

(x-ray, blood work)

Physicians office: $20 copay,


Emergency Room Services

Emergency medical

condition 20% coinsurance

after $200 copay

Urgent Care$20 copay/office visit;


Through Care Connex with AMPS and the PHCS network, all providers are in network*All facility/hospital claims are priced through AMPS.*Before services are rendered, verify that it does not require authorization.* Maximum annual out of pocket total is the combined deductible plus the coinsurance.** The coinsurance applies after the deductible has been reached.*** Copays accumulate toward coinsurance limits.


AMPS- Cost Containment Service

Your Trustees have partnered with AMPS, to combat rising healthcare costs.

AMPS assists members with all non-network (outside of PHCS and HealthSmart) providers and facility claims.

If a member receives a bill for a “balance” for facility services after they have paid their members share (responsibility) and AMPS is notified within 60 days of receiving the bill, AMPs will work directly withthe provider. The member is then protected.

Contact them at:

800-809-0513

Email- [email protected]

Further details are included on the health benefits website under the “AMPS” tab, at:





AMPS- Care Connex

Your Trustees are concerned about the rising cost of healthcare, so they are adding several new plays to your company’s healthcare playbook. Care Connex changes they way health benefits are delivered to you or your family:

Play 1: Contact Your Personal Care Navigator to schedule Surgery Center & Imaging Visits

Play 2: Contact Care Connex when you need a hospital. You can visit Any hospital you want, Care Connex may be able to arrange pre procedure pricing in advance

Play 3: Our Advocates Are Here For You contact them with any questions

Patient responsibility is the critical component of the Care Connex program. Any communication from a hospital or provider outside of patient responsibility must be provided within 60 days of receipt.

Patient Advocate: 888-641-8834

[email protected]



Magellan Rx – Pharmacy Benefits Manager

Magellan Rx is the pharmacy benefit manager on your plan.

Magellan Rx develops the formulary and can answer questions related to RX coverage and has an extensive

Online family mental health assistance

Program.

Customer Service : 800-711-4550

www.magellanhealth.com

Further details are included on the health benefits website under the “Pharmacy” tab, at:


http://www.magellanrx.com/



Prescription Benefits Summary

Prescription Drug Program Summary

Rx Benefit Generic Formulary Non-Formulary Specialty

Retail

Pharmacy

30 day

Supply

$10 copay

Or

Zero copay

(see list at Magellan)

$35 copay

50% of

prescription cost

up to a $100

maximum

50% of

Prescription

cost up to a

$500

maximum

Mail Order

Pharmacy

90 Day Supply

$20 copay $70 copay

50% of

prescription cost

up to a $200

maximum

N/A

Please talk to your doctor about Generic Alternatives to brand name medications when appropriate.

Please also talk to your doctor about using Over The Counter (OTC) or Zero Copay medications when appropriate.

Please see provider insurance booklets and Summary Plan Description (SPD)for the detailed benefit description and exclusions. This guide is not a guarantee of coverage or benefits.Summary Plan Description supersedes any information found in this employee benefits guide.This is only a partial illustration or overview of the policy and is not a legal document.

The Plan uses Magellan's prescription coupon program to assist members with High cost pharmaceuticals that have such programs. Members can save up to 100% of the copay. This will be internal and be realized at the time of filling.


Magellan Rx Value Max Program

The Value Max Program engages when the member initiates a high cost or biologic prescription. If a coupon program from the manufacturer is attached to the medication, Magellan will initiate the program to take full advantage of the coupon. This will result in copay savings to the member up to 100% of the copay.

This program is initiated by Magellan.


Delta Dental

Your dental benefits are administrated by Delta Dental.


www.deltadental.com

Further details are included on the health benefits website under the “Dental” tab, at:


http://www.deltadental.com/



Dental Benefits Summary

Dental Plan

The following Deductibles, Maximums and Benefits are per Participant:

Deductible Payment Levels

Plan Summary Delta

Dental PPO

Dentist

Delta Dental

Premier

Dentist

Nonparticipati

ng Dentist

Class I– Diagnostic & Preventive

Exams, X-Rays, Fluoride and Sealants 100%100% 100%

Class II—Restorative

Restoration, Endodontics,

Periodontics, Oral Surgery

100%100% 100%

Class III– Major

Crowns, Dentures, Partials, Bridges

and Implants

50%50% 50%

Annual Maximum Per Person

Benefit Period

(January 1-Dec 31)

$2,000 $2,000 $2,000

Deductible (Waived on Class 1)

Per person/per benefit period

Annual Family Max$0

$0

$50

$150

$50

$150

Orthodontia

Adults/Dependent Children

Lifetime max per person

50%

$1000

50%

$1000

50%

$1000

Staying in network may make your total annual max benefit stretch further. If you go out of network the plan pays at the 90% (or what 9 out of 10 providers charge for similar procedures in your area).

Please remember to have your dentist Pre-Authorize any large procedure before you have that procedure done.

Bi annual Teeth Cleaning is included in plan

Please see provider insurance booklets and Summary Plan Description (SPD) for the detailed benefit description and exclusions. This guide is not a guarantee of coverage or benefits.


VSP- Vision Benefit

Your vision benefits are administrated by VSP.


www.vsp.com

Further details are included on the health benefits website under the “Vision” tab, at:


http://www.vsp.com/



Vision Benefits Summary

VSP Vision

Eye Exams

Every 12 months (not calendar year)

$20 for exam and glasses

Lenses (single/bifocal/trifocal/basic transition)

Every 12 months (not calendar year)Combined with exam

Frames

Every 12 months (not calendar year)

$150 allowance for wide

selection of frames

$170 allowance for featured

frame brands

20% savings on the amount over

your allowance

Contact Lenses

(instead of glasses)

Copay up to $60

$150 allowance for contacts;

copay does not apply

Contact lens exam (fitting and

evaluation)

Please see provider insurance booklets and Summary Plan Description (SPD) for the detailed benefit description and exclusions. This guide is not a guarantee of coverage or benefits.Summary Plan Description supersedes any information found in this employee benefits guide.This is only a partial illustration or overview of the policy and is not a legal document.

Beginning 2020 each member may seek an additional $50 refund for frames and lenses costs through Cypress benefits.


Life & LTD (Not offered by Trust, but by Fire District 5)

Term Life

Basic Life $15000 included with LTD

Life Benefit5x earnings to $300,000 max

Guaranteed up to $100,000

Supplemental life for Spouse and

Dependents

Benefit:

Spouse up to $150,000

Guaranteed to$25,000

Dependents up to $2000

Portable Plus included

if employment ends for any reason.

See plan description for

details.

AD&D coverage see summary

plan document

Long Term Disability Insurance

Benefit Percentage: 60%

Maximum Monthly Benefit: $7,000*

Elimination Period: 90 Days

Benefit Duration:Based on age—please see summary plan

description for details

Duties based trigger for Benefits. Sick leave pay will not offset benefit under

100% pre disability earnings.

Please see provider insurance booklets and Summary Plan Description (SPD) for the detailed benefit description and exclusions. This guide is not a guarantee of coverage or benefits.Summary Plan Description supersedes any information found in this employee benefits guide.This is only a partial illustration or overview of the policy and is not a legal document

The group term life and LTD coverage is provided by Hartford.

For more information, contact:Katrina Lawrence253-851-3111www.gigharborfire.org

*Max benefit based on previous year salary


HRA- NueSynergy

The HRA will reimburse 100% of your Section 213D

expenses only. The Trust will fund your HRA as

follows:

What is an HRA?

An HRA is a tax-free Employer-Funded Health

Reimbursement Arrangement. The Trust, has

established the program (managed and administered by

IntegraFlex) to assist you in recovering medical, dental

and vision costs under Section 213D of IRS Code.

*Funds are invested with annual accounting.

Active Employee

employer participation *$535 on the last day of each month

Retirees, other Contribution amounts set through Employer

Rollover Feature

Rollover of unused

funds

The HRA plan renews each year every January 1st. Any

unused balance rolls over month to month and year to

year at 100%.

At termination of employment any unused balance will

remain in the account until exhausted.

*See the Summary Plan Description for a more

detailed explanation of the HRA rules and

application.

The (HRA) Health Reimbursement Arrangement is administered by NueSynergy and will pay out through the use of a debit card or reimbursement submittal.

*HRA funds are invested according to the Trust investment policy and reconciled annually. Proceeds or losses are determined and applied on or about March 1 of the following year.

Please see provider insurance booklets and Summary Plan Description (SPD) for the detailed benefit description and exclusions. This guide is not a guarantee of coverage or benefits.Summary Plan Description supersedes any information found in this employee benefits guide.This is only a partial illustration or overview of the policy and is not a legal document.


Regenexx Stem Cell Therapy

Visit the RegenexxWebsite for more information and dates for webinars explaining the process and benefits of this service.


Coordination of Benefits

Gig Harbor FF H&W Trust medical plan is the primary insurance coverage for the employee. In some cases, a member, spouse or dependents may have other medical plan coverage through a spouse’s employer or covered for a specific work related event by L&I . In order for the plan to coordinate, Cypress Benefits, the Trust Administrator will send an annual letter requiring a honest response. Members claims will be denied after a period if not returned, approved and received by Cypress.

In such cases where coverage from one or more plans exist, Coordination of Benefits can occur. Every medical plan has a well defined process for considering other coverage when processing claims. In these situations, you will likely be required to answer questions regarding your other coverage. It is a necessary part of the process that ensures that your claims are processed correctly while delivering you the maximum benefit available under the coordination of the different medical benefits.

It is important and your obligation under the plan, to notify the Trust Administrator, Cypress Benefits, in the event of any coordination of benefit situation that arises.


LBG Advisors – Additional Support

LBG Advisors, LLC is the plan consultant. Our firm helps participants with claims issues that may occur on the plan.

If you have tried contacting your benefit plan carriers and still cannot get resolution to your issue, please call LBG Advisors.

TF: 877-485-2120

Kris Kirkpatrick x 303, [email protected]



Gig Harbor Fire Benefits

To view all Trust offered plan documents and benefits information, visit the Trust Benefits website at:

www.gigharborfirebenefits.weebly.comfor more information.

Employer/HR Contact Info

Katrina LawrenceGig Harbor Fire & Medic One10222 Bujacich Rd NWGig Harbor, WA 98332253-851-3111 Main253-851-9606 Faxwww.gigharborfire.org


http://www.gigharborfire.org/


Required Notices

The U.S. government requires companies offering

certain employee benefit plans to inform covered

participants and their dependents about

laws/provisions that affect the governance and/or

coverage within those plans.

The Trust has created a page on their website with all

the required notices for you concerning the following

laws/provisions:

• Notice of HIPAA Special Enrollment Rights

• Wellness Program Disclosure Notice of Alternative

Standard

• Medicare Part D Notice

• Children’s Health Insurance Program

(CHIP) Notice

• Grandfather Status

• Notice of Patient Protection Provisions

• COBRA Notice

• Medical Child Support Order Notice

• Women’s Health and Cancer Rights Act

• Summary of Benefits and Coverage

• Mental Health Parity and Addiction Equity Act

(MHPAEA) Notice

Again, these notices can be found in the Your

Required Notices page of the Trust website. Unless

required, the Trust will consider the posting in this

location compliant with ERISA. For a more detailed

explanations about any of these notices, contact Kris

at LBG Advisors. Additionally, from time to time, you

may receive detailed explanations directly from the

company via letter or email.

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