2009 Benelect Guide - Medical
The purpose of this guide (print pdf version) is to provide you with an overview of Benelectthe flexible benefits program at Case. 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 the medical insurance carrier or Benefits Administration. Employees are responsible for selecting and using their benefits prudently and in the most cost-effective manner.
Medical Coverage
Medical benefits provide you and your family with financial protection and access to quality health care. Case medical plans cover expenses for pre-existing conditions. With Benelect, you have several medical plans and coverage levels from which to choose.
MMO Traditional
This comprehensive major medical health care plan does not place any restrictions on which health care provider members use. In this traditional indemnity plan, you must pay the annual deductible before Medical Mutual of Ohio (MMO) will begin to provide benefits. MMO pays for benefits for covered services through agreements with contracting institutional providers and participating physicians. For non-participating physicians and other professional providers, MMO pays for benefits based of usual, customary and reasonable (UCR) amounts. Visit mmoh.com >>.
Prescription coverage is through a separate pharmacy benefit management (PBM) carrier, Caremark. Visit caremark.com >> or search the Drug List >>.
Anthem Blue Access PPO
Anthem Blue Access is a preferred provider organization (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.
Prescription coverage is through a separate pharmacy benefit management (PBM) carrier, Caremark. Visit caremark.com >> or search the Drug List >>.
Kaiser HMO
This health maintenance organization (HMO) operates medical facilities in the Greater Cleveland and Akron areas. Kaiser includes all of the important benefits you expect from a health care planquality care and service, comprehensive coverage including prescription benefit, convenience, low co-payments, no deductibles, and no claim forms. Visit kaiserpermanente.org >>.
SuperMed PPO
This preferred provider organization (PPO) allows you full access to medical care from any physician or hospital in the provider network (SuperMed 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. Visit SuperMed PPO online at mmoh.com >>.
Prescription coverage is through a separate pharmacy benefit management (PBM) carrier, Caremark. Visit caremark.com >> or search the Drug List >>.
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
- 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.
GLOSSARY OF BENEFITS TERMS
- COBRA
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.
- conventional/indemnity/traditional
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.
- co-payment
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.
- co-insurance
The portion of covered health care costs for which the covered person has a financial responsibility, usually according to a fixed percentage.
- deductible
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 healthcare 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 healthcare 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.
- Medicare
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 >>.
- members
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.
- premium
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.
- provider
A physician, hospital, group practice, nursing home, pharmacy, or any individual or group of individuals that provides a health care service.
- referral
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.
- subscriber
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).
- utilization
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.
