2016 Benelect Guide - Medical
The purpose of this guide (print or view pdf version) is to provide you with an overview of Benelect - the flexible benefits program at CWRU. This is not intended to be a comprehensive description of the benefit plans. Details of individual benefit plans are provided in legal plan documents and contracts that govern the operation of the program. Specific coverage information is contained in the individual summary plan descriptions available from Benefits Administration (320 Crawford Hall). Employees are responsible for selecting and using their benefits prudently and in the most cost-effective manner. Under no circumstances are the statements contained in these policies to be considered a contract of employment, an obligation, or guarantee on the part of the university. Please call 216-368-6781 or e-mail AskHR@case.edu with any questions, comments, or concerns that you may have.
Medical benefits provide you and your family with financial protection and access to quality health care. CWRU medical plans cover expenses for pre-existing conditions. With Benelect, you have several medical plans and coverage levels from which to choose.
Anthem Blue Access is a PPO program which allows you access to the nation's largest network of doctors and hospitals in Ohio, throughout the U.S. and even Worldwide. You do not need to designate a Primary Care Physician, nor do you need referrals for services.
The SuperMed Plus PPO allows you full access to medical care from any physician or hospital in the provider network (Provider Search). Medical Mutual of Ohio (MMO) offers SuperMed Plus, which utilizes an extensive network of hospitals and physicians, but the ultimate choice of providers is yours. SuperMed Plus also includes coverage for medical emergencies in your area, or wherever you travel. For more information view the MMO health benefits FAQ (pdf) or visit SuperMed PPO online at mmoh.com.View the Medical Mutual Supermed Plus Certificate of Coverage - Plan 1 (pdf) or the Medical Mutual Supermed Plus Certificate of Coverage - Plan 2 (pdf)
Prescription coverage for both PPO plans is through a separate pharmacy benefit management (PBM) carrier, Caremark (www.caremark.com). If you are taking a long-term medication, the plan allows two 30-day fills for a low co-payment at any pharmacy in the CVS Caremark network. If you continue to get 30-day fills after that, you will pay a higher co-pay. With Maintenance Choice, you can avoid paying more for your long-term medication(s) by having 90-day supplies filled through the mail order pharmacy or at your local CVS pharmacy.
Generic Step Therapy requires members in the PPO health plan options to try a cost-effective generic drug before a non-preferred single source brand-name drug is covered. For many people, generic medicines work just as well as other medicines but cost significantly less. Brand-name medicines included in the program cover treatments for 18 health conditions, such as asthma, depression, high blood pressure and high cholesterol. Your doctor can contact CVS Caremark to request a prior authorization if you have a unique medical situation that requires you to keep taking the brand-name medicine. A listing of health conditions and brand name medications covered by the program can be found by clicking here.
The medical co-pay, prescription co-pay, deductible and co-insurance accumulate toward annual out-of-pocket limits for both PPO plans.
Select Plus through HealthSpan (formerly Kaiser Permanente of Ohio) is an alliance of 4 physician groups, or Clinically Integrated Networks (CINs): HealthSpan Integrated Care Physicians & Mercy Health Physicians; MetroHealth Physicians; NewHealth Collaborative (Summa Health System); and University Hospitals Physicians. In a CIN, your physicians, specialists and hospitals collaborate to improve health outcomes and work together to deliver you the most efficient and high-quality care. HealthSpan Select Plus includes all of the important benefits you expect from a health care plan: quality care and service, comprehensive coverage including prescription benefit, convenience, low co-payments, no deductibles, and no claim forms. Visit healthspan.org for complete details.
View the HealthSpan Select Plus provider directory (pdf)
View the HealthSpan Certificate of Coverage (pdf)
High Deductible Health Plan (HDHP)
The Anthem HDHP and Health Savings Account (HSA) combine comprehensive medical coverage and a tax-advantaged savings account. The HDHP provides access to high quality health care through Anthem's provider network. The plan pays a large part of medical costs after the deductible is met and your expenses are limited by an out-of-pocket maximum. The HDHP does have a higher deductible, however, the deductible can be offset by employee contributions to a Health Savings Account (HSA).
Prescription coverage is through a separate pharmacy benefit management (PBM) carrier, Caremark (www.caremark .com). Your prescription costs are applied to your deductible. If you are taking a long-term medication, the plan allows two 30-day fills for a low co-payment at any pharmacy in the CVS Caremark network. If you continue to get 30-day fills after that, you will pay a higher co-pay. With Maintenance Choice, you can avoid paying more for your long-term medication(s) by having 90-day supplies filled through the mail order pharmacy or at your local CVS pharmacy.
Generic Step Therapy requires members in the HDHP option to try a cost-effective generic drug before a non-preferred single source brand-name drug is covered. For many people, generic medicines work just as well as other medicines but cost significantly less. Brand-name medicines included in the program cover treatments for 18 health conditions, such as asthma, depression, high blood pressure and high cholesterol. Your doctor can contact CVS Caremark to request a prior authorization if you have a unique medical situation that requires you to keep taking the brand-name medicine. A listing of health conditions and brand name medications covered by the program can be found by clicking here.
You cannot participate in the health care flexible spending account (FSA) under this option. Instead, you have a different medical savings option available to you. The medical savings feature is a Health Savings Account (HSA) -- an IRS-qualified feature that provides substantial tax savings and participant flexibility. The account is owned by the employee. This means that account balances roll over from year to year, even when you leave the university. The account has the flexibility to be used for current medical expenses or money can be left in the account to save for future health care expenses. Contributions, interest, and investment earnings are not subject to federal, state, or FICA taxes. You must be enrolled in the HDHP to contribute in an HSA. You cannot contribute to an HSA if you are enrolled in a medical plan that is not a high deductible plan. For example, if you are enrolled in Medicare, or have secondary coverage through a spouse's plan, or your spouse has a medical flexible spending account that can be used to reimburse family member expenses, you may not be eligible to contribute to an HSA.View the Anthem HDHP Certificate of Coverage - Individual (pdf) or the Anthem HDHP Certificate of Coverage - Family (pdf)
Waive Medical Coverage
If you already have medical coverage, another option is "waive." You can choose this option only if you indicate that you have coverage under another medical plan when you enroll.
Medical Coverage Level
Once you choose the medical option that is right for you, you also choose the number of people to cover. You may choose from these coverage categories:
- Employee + Child(ren)
- Employee + Spouse (Equivalent)
- Employee + Family
Coordination of Benefits
If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Read all of the rules very carefully, including the coordination of benefits section in the plan material and compare them with the rules of any other plan that covers you or your family.
Working Spouse Premium Surcharge
If your spouse or equivalent has access to a health plan through their employer, but you choose to cover her/him through Benelect, you will pay a premium surcharge.
GLOSSARY OF BENEFITS TERMS
Abbreviation for Consolidated Omnibus Budget Reconciliation Act of 1985. Part of this law requires employers to continue offering health coverage for enrollees and their dependents for a period of time after an enrollee leaves the employer. Typically, the employee pays the entire monthly premium when covered by COBRA. Read COBRA coverage information for more details.
Plan participants have no restrictions on which health care providers they use. Plan participants or providers are reimbursed following submission of a claim on a fee-for-service basis. All providers of the same service are reimbursed at the same level.
A fixed sum and/or percentage that an enrollee pays for specific health services, regardless of the total charge for service (the insurer pays the rest of the total charge). For example, an enrollee may pay $10 co-payment and 20 percent of the total charge for each doctors office visit, $75 for each day in the hospital, and $25 for each prescription.
The portion of covered health care costs for which the covered person has a financial responsibility, usually according to a fixed percentage.
A predetermined annual amount an enrollee must pay before the insurer will begin paying their portion of covered expenses. For example, if the plan has a $400 deductible, the insured person would be responsible for the first $400 of his/her health care bills.
- domestic partner
see definition of spouse equivalent.
- drug formulary
A listing of prescription medications (name brand and generic) which are preferred for use by the health plan, and which will be dispensed through participating pharmacies to covered persons. This list is subjected to periodic review and modification by the pharmacy benefit management plan.
- eligible person/employee
One who meets the requirements specified to qualify for coverage under a health plan.
- eligibility date
The defined date a covered person becomes eligible for benefits under an existing contract.
- evidence of coverage
A detailed description of the benefits included in the health plan. An evidence/certificate of coverage is required by state laws and representative of the coverage provided under the contract issued to an employer.
- health maintenance organization (HMO)
Plan participants obtain comprehensive health care services from a specified list of in-network providers who receive a fixed periodic prepayment from the insurer. Plan participants access to in-network providers is controlled by a primary-care physician or gatekeeper. HMO's typically do not have a deductible.
- managed care
A system of health care delivery that influences utilization and cost of services and measures performance. The goal is a system that delivers value by giving people access to quality health care in a cost-effective way.
- medically necessary
The evaluation of health care services to determine if they are: medically appropriate and necessary to meet basic health needs; consistent with the diagnosis or condition and rendered in a cost effective manner; and consistent with national medical practice guidelines regarding type, frequency and duration of treatment.
A nationwide, federally administered health insurance program which partially covers the costs of hospitalization, Medicare care, and some related services for eligible persons. Medicare has two parts: Part A covers inpatient costs. Medicare pays for pharmaceutical services provided in hospitals, but not for those provided in outpatient settings. Also called Supplementary Medical Insurance. Part B covers outpatient costs (i.e. physician office visits, lab, and x-ray). Visit medicare.gov.
Participants in health plan (subscribers/ enrollees and eligible dependents), who make up the plan's enrollment.
- pre-existing condition
Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage under the group contract.
- preferred provider organization (PPO)
Plan participants may seek care from an in-network provider or from an out-of-network provider, but the plan makes no provision to couple a patient with a primary-care physician or gatekeeper. Typically, the patient pays more for services from an out-of-network provider.
The amount paid by an enrollee and/or employer to an insurance company/carrier for coverage.
- preventive care
Comprehensive care emphasizing priorities for prevention, early detection, and early treatment of conditions, generally including routine physical examination, immunization, and well person care.
- primary care
Basic or general health care, traditionally provided by family practice, pediatrics, and internal medicine.
- primary care physician (PCP)
A physician the majority of whose practice is devoted to internal medicine, family/general practice and pediatrics.
A physician, hospital, group practice, nursing home, pharmacy, or any individual or group of individuals that provides a health care service.
The recommendation by a physician and/or health plan for a covered person to receive care from a different physician or facility.
- second opinion
An opinion obtained from an additional health care professional prior to the performance of a medical service or a surgical procedure. May relate to a formalized process, either voluntary or mandatory, which is used to help educate a patient regarding treatment alternatives and/or to determine medical necessity.
- service area
The geographic area serviced by a health plan as approved by state regulatory agencies.
- spouse equivalent
The same- or opposite-sex domestic partner of a benefits-eligible employee. Eligibility for medical and dental insurance is contingent upon completion of affidavit.
The person responsible for payment of premiums or whose employment is the basis for eligibility for membership in an HMO or other health plan.
- usual, customary and reasonable amount (UCR amount)
the maximum amount allowed (reimbursable) for a covered service provided by a physician and other professional provider based on the provider criteria (see appropriate certificates of coverage).
The extent to which the members of a covered group use a program or obtain a particular service, or category of procedures, over a given period of time.