Insurance Summary Plan Description
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Summary Plan Description Effective January 1, 2018 Ohio Laborers’ District Council - Ohio Contractors’ Association Insurance Fund Ohio Laborers’ District Council – Ohio Contractors’ Association Insurance Fund 800 Hillsdowne Road Westerville, OH 43081-3302 (614) 898-9006 or (800) 236-6437 Fax: (614) 898-9176 www.olfbp.com [email protected] Dear Member: We are pleased to provide you with this Plan Document/Summary Plan Description (“SPD”). This booklet describes all the benefits provided to you by the Ohio Laborers’ District Council – Ohio Contractors’ Association Insurance Fund (“Fund”). Please read this booklet carefully, share it with your family, and reference it when you have questions regarding your insurance benefits. If you have any questions about the information contained in this booklet or about your insurance benefits in general, please don’t hesitate to contact the OLFBP Fund Office. Sincerely, OLFBP and the Board of Trustees 1 Table of Contents Schedule of Benefits ...................................................................................................................................... 3 Introduction .................................................................................................................................................. 13 Contact Information ................................................................................................................................................. 13 Updating Your Address ............................................................................................................................................ 14 Reciprocity ............................................................................................................................................................... 14 Class 1 Eligibility – Active Members ............................................................................................................. 18 Class 2 Eligibility – Disability Due to End Stage Renal Disease (ESRD) ..................................................... 25 Class 3 Eligibility – Retired Members between the Ages of 53 and 65 ........................................................ 27 Class 4 Eligibility – Retired Members Eligible for Medicare ......................................................................... 30 Dependent Eligibility .................................................................................................................................... 33 Additional Eligibility Information ................................................................................................................... 37 COBRA ........................................................................................................................................................ 38 USERRA Continuation Coverage ................................................................................................................ 42 Medical Benefits .......................................................................................................................................... 45 Coordination of Benefits .............................................................................................................................. 68 Prescription Drug Benefits ........................................................................................................................... 73 Vision Benefits ............................................................................................................................................. 81 Hearing Benefits .......................................................................................................................................... 85 Short Term Disability ................................................................................................................................... 87 Death Benefits ............................................................................................................................................. 90 Accidental Death & Dismemberment ........................................................................................................... 93 Appeals ........................................................................................................................................................ 95 General Plan Exclusions and Limitations ................................................................................................... 107 General Claims Information ....................................................................................................................... 113 HIPAA Privacy and Security ...................................................................................................................... 118 Subrogation and Reimbursement .............................................................................................................. 120 Administrative Information ......................................................................................................................... 122 Your ERISA Rights .................................................................................................................................... 127 Other Federal Legislation .......................................................................................................................... 129 Glossary .................................................................................................................................................... 130 2 Medical Benefits Schedule of Benefits Claims Administrator: Anthem Blue Cross Blue Shield (855) 878-0128 Medicare Eligible Retirees and Medicare Eligible Dependents of Retirees (Medical and Rx) Plan details not in this booklet, will be mailed separately by Humana. Humana Customer Care - (800) 733-9064 Out-of-Network Network Coverage Coverage Benefit Period January 1st through December 31st Pre-Existing Condition Waiting Period No Pre-Existing Rules Annual Deductible All claims will be subject to the annual Deductible, unless $400 per person* $800 per person* otherwise noted. Before the Fund pays for most Covered $800 family maximum $1,600 family maximum Expenses, you pay: Maximum Out-Of-Pocket (MOOP) Limit The Fund pays 100% for the remainder of the year once $6,750 per person $3,375 per person you reach your MOOP Limit. MOOP Limit includes $13,500 family $6,750 family maximum Deductibles, Copayments, and Coinsurance, but does not maximum include penalties or balance billings or claims denied as Rates subject to change Rates subject to change not medically necessary. Any future increases in the limits annually. established in accordance with the ACA shall be split annually. evenly between the medical and prescription limits. Coinsurance 80%, then 100% after 60%, then 100% after All claims will be subject to the Coinsurance, unless the annual Out-of- the annual Out-of- otherwise noted. Once you meet your annual Deductible, Pocket Maximum is Pocket Maximum is the Fund pays: reached reached 100% Office Visit – LiveHealth Online Not Subject to Visit a doctor for free on your smartphone, tablet, or Not Covered Copayment or computer with webcam. Deductible Office Visit – Primary Care Providers Applies to the cost of Office Visit only (including $20 Copayment, then $20 Copayment, then consultation services). All other covered charges are Fund pays 100% Fund pays 60% subject to Deductible and Coinsurance. Office Visit - Specialists Applies to the cost of Office Visit only (including $30 Copayment, then $30 Copayment, then consultation services). All other covered charges are Fund pays 100% Fund pays 60% subject to Deductible and Coinsurance. Urgent Care $50 Copayment, then $50 Copayment, then Applies to the cost of Office Visit only. Fund pays 100% Fund pays 60% 3 Emergency Room $150 Copayment, Copayment Waived if Admitted Applies to room charges only. All other covered charges Fund pays 100% for room charges, 80% for all other are subject to Coinsurance, but not subject to Deductible. covered charges Routine Physical Exam – Office Visit $20 Copayment, then Once per Calendar Year. Fund Pays 60% Routine Tests EKG, Chest X-ray, Complete Blood Count, Digital Rectal Exam, Cholesterol Screening, Prostate Specific Antigen (PSA), Comprehensive Metabolic Panels, and Urinalysis. Tests covered once per Calendar Year. Preventive Services Services include evidence based services that have a rating of “A” or “B” in the United States Preventive Services Task Force, routine immunizations, and other screenings as provided for in the Patient Protection and Affordable Care Act. Age and other restrictions apply to certain services. Examples: Colonoscopies only 100% covered for ages 50 to 75, Bone Density Testing only Not Subject to covered for women age 60 and older, Herpes Zoster Copayment or (shingles) Vaccine covered age 60 and older, HPV Deductible 60% Vaccine covered under age 27. Well Child Care Plan pays for Preventive Services covered under the Affordable Care Act for children through age 20. Age and other restrictions apply to certain services. Birth Control for Women All contraceptive methods for women approved by the FDA. Certain restrictions may apply. Routine PAP Smear Test Routine Mammogram – Age 40 and Older Once per Calendar Year. Routine Mammogram – Under Age 40 80% 60% Once per Calendar Year. Influenza Virus Vaccine (Flu Shots) 100% Behavioral Health Care & Substance Abuse – In Patient You must obtain approval before Hospital admission, 80% 60%