Lumen Retiree and Inactive Health Care Plan* Standard Consumer
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Lumen Retiree and Inactive Health Care Plan * Standard Consumer Driven Health Plan (CDHP) (Administered by UnitedHealthcare) Summary Plan Description (SPD) For Retired and Inactive Former Employees CenturyLink, Embarq, Qwest Post-1990 Management, Qwest Post-1990 Occupational Retirees (including Inactive and COBRA Participants) Effective January 1, 2021 This SPD must be read in conjunction with the Retiree General Information SPD , which explains many details of your coverage and provides a listing of the other Benet options under the Plan. * The Lumen brand was launched on September 14, 2020. As a result, Lumen, Inc. is referred to as Lumen Technologies, or simply Lumen. The legal name Lumen, Inc. is expected to be formally changed to Lumen Technologies, Inc. upon the completion of all applicable requirements. Issued Jan. 1, 2021 Table of Contents INTRODUCTION 1 The Patient Protection and Affordable Care Act Known as the “Affordable Care Act” ....................................... 1 The Required Forum for Legal Disputes .......................................................................................................... 2 How to Use This Document ............................................................................................................................... 2 Exempt Retiree Medical Plan Status Notice ...................................................................................................... 2 Lumen’s right to use your Social Security number for administration of benets .............................................. 3 GENERAL PLAN INFORMATION 3 You May Not Assign Your Benets to Your Provider ......................................................................................... 4 Consequences of Falsication or Misrepresentation ......................................................................................... 4 Plan Number ...................................................................................................................................................... 5 CLAIMS ADMINISTRATOR (UHC) AND CONTACT INFORMATION 5 Consumer Solutions and Self-Service Tools ..................................................................................................... 6 UNITEDHEALTHCARE STANDARD CDHP PLAN BENEFIT OPTION (STANDARD CDHP) 7 Eligibility ............................................................................................................................................................. 7 About the Standard CDHP Benet Option and HRA ......................................................................................... 8 What is the HRA? .............................................................................................................................................. 8 STANDARD CDHP PLAN FEATURES AND HOW THE PLAN WORKS 8 Network and Out-of-Network Benets and Providers (for those residing in a Network area). ........................... 9 Out-of-Network Benets Exception (Gap Exception) ...................................................................................... 10 Virtual Network Benets .................................................................................................................................. 10 Network and Out-of-Network Providers/Facilities (for Virtual Network) ........................................................... 10 Premium SM Tier Providers and Freestanding Facilities .................................................................................... 11 How to Find a Premium Provider or a Freestanding Facility: .......................................................................... 11 Eligible Expenses ............................................................................................................................................ 11 Annual Deductible ........................................................................................................................................... 12 Coinsurance .................................................................................................................................................... 12 Out-of-Pocket Maximum .................................................................................................................................. 12 How the Standard CDHP Works with an HRA ................................................................................................. 13 YOUR HEALTH REIMBURSEMENT ACCOUNT (HRA) 14 Annual HRA Allocation ..................................................................................................................................... 14 Annual Member Responsibility ........................................................................................................................ 15 Annual Out-of-Pocket Maximum ...................................................................................................................... 15 HRA Dollars and Deductible for Mid-Year Enrollments/Changes .................................................................... 16 HRA – Qualifying Life Events .......................................................................................................................... 16 Moving to HDHP .............................................................................................................................................. 16 HOW TO ACCESS YOUR HRA DOLLARS 17 Health Care Spending Card (HCSC) ............................................................................................................... 17 Using the Health Care Spending Card ............................................................................................................ 17 Substantiation .................................................................................................................................................. 18 Member Health Statements and HRA Yearly Statements ............................................................................... 19 HRA CLAIM PROCEDURES 19 Auto HRA Claims Submission ......................................................................................................................... 19 Network Benets ............................................................................................................................................. 19 Manual HRA Claim Submission ....................................................................................................................... 19 Out-of-Network Benets .................................................................................................................................. 19 Out-of-Network Prescription Drug Benet HRA Claims ................................................................................... 20 2021 Retiree SPD|Lumen, CenturyLink, Embarq, Qwest Post-1990 Management and Qwest Post-1990 Occupational ii Retirees (including Inactive and COBRA Participants) | Issued Jan. 1, 2021 FILING A MANUAL HRA CLAIM 20 Request for Withdrawal Form .......................................................................................................................... 20 Health Statements ........................................................................................................................................... 21 Explanation of Benets (EOB) ......................................................................................................................... 21 WELL CONNECTED (CASE MANAGEMENT) 21 Personal Health Support Nurse Services ........................................................................................................ 22 COVERED STANDARD CDHP BENEFITS (WITH HRA) BENEFITS 24 Plan Highlights (Standard CDHP Network and Virtual Networks) ................................................................... 24 Covered Benets Summary Table ................................................................................................................... 25 Multiple Surgical Procedure Reduction Policy ................................................................................................. 30 ABA Therapy .................................................................................................................................................. 31 Abortion ........................................................................................................................................................... 31 Acupuncture Services ...................................................................................................................................... 31 Ambulance Services - Emergency Only .......................................................................................................... 31 Cancer Resource Services (CRS) ................................................................................................................... 32 Cellular and Gene Therapy ............................................................................................................................. 32 Clinical Trials ................................................................................................................................................... 33 Prior Authorization is required for Clinical Trials. ............................................................................................. 34 Congenital Heart Disease (CHD) Surgeries .................................................................................................... 34 Dental Services - Accident Only .....................................................................................................................