Independent Colleges and Universities Benefits Association, Inc
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INDEPENDENT COLLEGES AND UNIVERSITIES BENEFITS ASSOCIATION, INC. MEDICAL, BEHAVIORAL HEALTH, AND PRESCRIPTION DRUG PLAN DOCUMENT April 1, 2015 THIS DOCUMENT IS FOR ALL EMPLOYEES AND OTHER BENEFICIARIES ELIGIBLE FOR BENEFITS UNDER THE INDEPENDENT COLLEGES AND UNIVERSITIES BENEFITS ASSOCIATION MEDICAL, BEHAVIORAL HEALTH, AND PRESCRIPTION DRUG PLAN INDEPENDENT COLLEGES AND UNIVERSITIES BENEFITS ASSOCIATION, INC. ORLANDO, FLORIDA HTTP://ICUBABENEFITS.ORG 866-377-5102 July, 2015 Table of Contents Article Title Page One Introduction ............................................................................................................................................ 3 Two Plan Identifying Information.................................................................................................................... 5 Three Blue Cross Blue Shield of Florida (FLORIDA BLUE) Services ............................................................... 8 Four Schedule of Medical and Behavioral Health Benefits, including Employee Assistance Program ........................ 14 Five Utilization Review Process ................................................................................................................... 24 Six Prescription Drug Benefits ................................................................................................................... 28 Seven Enrollment and Contributions ............................................................................................................... 43 Eight Continuation of Coverage .................................................................................................................... 51 Nine Covered Expenses ............................................................................................................................... 66 Ten Limitations and Exclusions ................................................................................................................... 84 Eleven Coordination of Benefits ....................................................................................................................... 91 Twelve Coordination of Benefits with Medicare ................................................................................................ 96 Thirteen Claims and Appeals Procedures ........................................................................................................ 103 Fourteen Health Insurance Portability and Accountability (HIPAA) Privacy Notice ........................................... 113 Fifteen You’re Rights Under ERISA ............................................................................................................... 120 Sixteen General Plan Provisions .................................................................................................................... 122 Seventeen Plan Administrator Duties and Powers ............................................................................................... 124 Eighteen Amendments, Terminations and Mergers .......................................................................................... 125 Glossary Definitions .......................................................................................................................................... 126 Riders (There are 22 Riders) ........................................................................................................................... 145 ii ARTICLE ONE INTRODUCTION The Independent Colleges and Universities Benefits Association, Inc. Medical, Behavioral Health, and Prescription Drug Plan (the “Plan”) was adopted on April 1, 2003 by the six founding Member Institutions of the Independent Colleges and Universities Benefits Association, Inc. (“ICUBA”). There are currently 25 Member Institutions: Arthur I. Meyer Jewish Academy (effective 1/1/2013) Barry University (effective 1/1/2006) Beacon College (effective 10/1/2005) The Bolles School (effective 7/1/2010) Central Florida Area Health Education Center (effective 4/1/2011) Clearwater Christian College (effective 4/1/2003) Corbett Preparatory School of IDS (effective 12/1/2012) Edward Waters College (effective 11/1/2003) Everglades Area Health Education Center (effective 4/1/2011) Florida Institute of Technology (effective 4/1/2003) Florida Memorial University (effective 1/1/2008) Good Shepherd Episcopal School (effective 12/1/2011) Grace Episcopal Day School (effective 9/1/2014) Jacksonville Country Day School (effective 9/1/2013) Nova Southeastern University (effective 4/1/2003) Palm Beach Atlantic University (effective 4/1/2003) The Poynter Institute (effective 1/1/2011) Rollins College (effective 4/1/2003) Saint Edward’s School (effective 9/1/2009) Saint Leo University (effective 6/1/2003) St. Mark’s Episcopal Day School (effective 7/1/2011) Saint Paul’s School (effective 7/1/2010) San Jose Episcopal Day School (effective 7/1/2010) Tampa Preparatory School (effective 5/1/2011) The University of Tampa (effective 6/1/2003) On March 14, 2003, the Florida Department of Financial Services granted ICUBA a Certificate of Authority to operate as a self-funded non-profit Multiple Employer Welfare Arrangement operating as a health care cooperative pursuant to Section 624.436, Florida Statutes. This document amends and restates the Plan, effective April 1, 2015. A current version of the Plan will always be available on ICUBA’s website at http://icubabenefits.org. The Plan has been approved by the Board of Directors of ICUBA. It is intended to meet the requirements of the Employee Retirement Income Security Act of 1974 (“ERISA”). In addition, the Plan is a Voluntary Employees’ Beneficiary Association and is intended to meet the requirements of Section 501(c)(9) of the Internal Revenue Code of 1986 (the “Code”) and the Regulations promulgated thereunder, as amended from time to time. 3 This document and any amendments constitute the governing document of the Plan. The Plan is designed and administered exclusively for the benefit of eligible beneficiaries. You are entitled to coverage under the Plan if the eligibility provisions of the Plan have been satisfied. A clerical error shall not invalidate Your Benefits under the Plan if You are otherwise entitled to Benefits under the Plan. The Board of Directors intends to maintain the Plan indefinitely. However, the Board of Directors has the right to modify or terminate the Plan at any time, and for any reason, as to any part or in its entirety, without advance notice in accordance with the Patient Protection and Affordable Care Act of 2010. If the Plan is amended or terminated, You may not receive Benefits described in the Plan after the effective date of such amendment or termination. Any such amendment or termination shall not affect Your right to Benefits for Claims incurred prior to such amendment or termination. If the Plan is amended, You may be entitled to receive different Benefits or Benefits under different conditions. However, if the Plan is terminated, all Benefit coverage will end. This may happen at any time. If the Plan is terminated, You will not have any vested rights under the Plan. You may, however, have a vested right to a benefit under Your Employer’s Health Reimbursement Account Plan, if any (see Your Health Reimbursement Account Plan Document). Oral statements or representations by anyone, which are contrary to this Plan document are not authoritative sources of information and may not be relied upon. Advice on Reading this Document Some of the terms used in this Plan Document begin with a capital letter. These terms have special meaning under the Plan and are defined in the Glossary, which is located at the end of this Plan Document. Other capitalized terms used within this Plan Document may be defined within their relevant Article. When reading the provisions of the Plan, You can refer to the Glossary at the end of this Plan Document. Becoming familiar with the terms defined therein will give You a better understanding of the procedures and Benefits described herein. There are twenty-two riders that accompany this Plan. Depending upon Your Employer, these riders may or may not apply to You. It is important that You read the attached riders and determine whether they apply to You. This Plan Document constitutes the Summary Plan Description required by ERISA Section 102. 4 ARTICLE TWO PLAN IDENTIFYING INFORMATION NAME OF THE PLAN Independent Colleges and Universities Benefits Association, Inc. Medical, Behavioral Health and Prescription Drug Plan TYPE OF PLAN Self-Funded Non-Profit Medical, Behavioral Health, and Prescription Drug Plan FUNDING MEDIUM AND TYPE OF Florida Blue is the claims administrator and processes claim under PLAN ADMINISTRATION the Medical program through Florida Blue. Catamaran is the pharmacy benefit manager under the Prescription Drug program. MHNet Behavioral Health is the claims administrator and processes all behavioral health claims. Florida Blue, Catamaran, and MHNet Behavioral Health do not serve as insurers, but as Claims processors and Network Providers. Claims are paid out of the assets of ICUBA, which receives contributions from Member Institutions and Participants, and holds those assets in trust for the exclusive benefit of Beneficiaries. MHNet Behavioral Health provides Employee Assistance Program Services on a capitated fee basis. ADDRESS OF PLAN ICUBA 4850 Millenia Blvd., Suite 329 Orlando, FL 32839 AGENT FOR Mark S. Weinstein, President & CEO SERVICE OF LEGAL PROCESS 4850 Millenia Blvd., Suite 329 Orlando,