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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
For this plan year, the plan includes the following provisions, subject to change or discontinuation with or without
notice at anytime.
This Summary Plan Description presents an overview of your Benefits. In the event of any discrepancy between
this Summary Plan Description and the official Plan Document, the Plan Document shall govern.
Table of Contents
.
Medical Plan – Choice Fund (HRA) .......................................................................................................1
Your Medical Plan Options ....................................................................................................................1
If the Plans Are Ended or Modified ..................................................................................................1
No Implied Promises .......................................................................................................................1
No Coverage ...................................................................................................................................1
What is Managed Care?.........................................................................................................................2
Opportunity to select a Primary Care Physician ...............................................................................2
CIGNA Choice Fund (HRA) ....................................................................................................................2
Health Reimbursement Account (HRA) ...........................................................................................2
Co-Insurance...................................................................................................................................2
Additional Features .........................................................................................................................3
Who is Eligible for the Medical Plan? ...................................................................................................3
Eligible Dependents ........................................................................................................................3
Incapacitated Children.....................................................................................................................3
Change Enrollment Elections during Year .......................................................................................3
Qualified Medical Child Support Order (QMCSO) ............................................................................ 4
Notification of Qualifying Events that Result in Loss of Coverage .................................................... 4
An Overview of Your CIGNA Choice Fund (HRA) Benefits ................................................................. 5
Premium Payments or Fees to Purchase Coverage ........................................................................ 5
Annual Deductible ...........................................................................................................................5
Your HRA ........................................................................................................................................5
Your Share ......................................................................................................................................5
Co-Insurance...................................................................................................................................6
Annual Out-of-Pocket Maximum Amounts .......................................................................................7
Additional Features ...............................................................................................................................8
Online Health Risk Assessment ......................................................................................................8
Online Coaching Programs .............................................................................................................8
Coaching Support for Chronic Conditions ........................................................................................8
HRA Extras .....................................................................................................................................8
Covered Services under the Medical Plan ...........................................................................................8
Hospital Expenses (Inpatient and Outpatient)................................................................................ 14
Surgical Services ..........................................................................................................................14
Medical Services ...........................................................................................................................14
Transplant Surgery ........................................................................................................................15
Home Health Care.........................................................................................................................15
Hospice Care ................................................................................................................................15
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
Chiropractic Care ..........................................................................................................................15
Foreign Claims ..............................................................................................................................16
Dental Services and Oral Surgery ................................................................................................. 16
Clinical Trials .................................................................................................................................16
Genetic Testing .............................................................................................................................16
Services Not Covered Under the Medical Plan .................................................................................. 17
Non-covered General Medical Services ........................................................................................ 17
Non-covered Home Health Care Services ..................................................................................... 19
Non-covered Hospice Care Services ............................................................................................. 20
Pre-Authorization Certification for Services and Continued Stay Review for Inpatient Care......... 20
How Do I Start the Precertification Process? ................................................................................. 20
What Happens if I Do not Pre-certify? ........................................................................................... 20
Maternity Hospital Stays .....................................................................................................................21
Prescription Drug Coverage................................................................................................................ 21
Retail Pharmacy Program ............................................................................................................. 21
Mail Order Program .......................................................................................................................21
Step Therapy.................................................................................................................................22
Formulary Rebate .........................................................................................................................22
Covered Expenses under the Prescription Drug Program ............................................................. 22
Non-covered Expenses under the Prescription Drug Program ...................................................... 22
Behavioral Health Care Benefits ......................................................................................................... 23
How Behavioral Health Care Benefits Work .................................................................................. 23
Other Medical Plan Services ............................................................................................................... 23
CIGNA’s Toll-Free Care Line ......................................................................................................... 23
Case Management ........................................................................................................................23
How to Request Case Management Services ............................................................................... 24
CIGNA LIFESOURCE Organ Transplant Network ......................................................................... 24
Medical Plan Claim Information .......................................................................................................... 25
How to File a Medical Plan Claim .................................................................................................. 25
Claim Reminders ...........................................................................................................................25
Payment of Benefits ......................................................................................................................25
When You Will Receive Payment .................................................................................................. 26
Post-Service Claims ......................................................................................................................26
Pre-Service Claims........................................................................................................................26
Urgent Care Claims .......................................................................................................................26
Concurrent Care Claims ................................................................................................................27
Questions about Benefit Determinations ....................................................................................... 27
How to File an Appeal ...................................................................................................................27
First Level Appeals ........................................................................... Error! Bookmark not defined.
Second Level Appeals ...................................................................... Error! Bookmark not defined.
Urgent Care Appeals ........................................................................ Error! Bookmark not defined.
Independent Review Procedure ....................................................... Error! Bookmark not defined.
Recovery of Overpayment ............................................................................................................. 29
What Happens to Your Medical Plan Benefits When You Leave the Company? ............................. 29
When Medical Plan Coverage Ends .............................................................................................. 29
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Deluxe Corp.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
How to Continue Medical Plan Coverage ...................................................................................... 29
Guidelines Affecting Your Medical Plan Benefits .............................................................................. 29
Coordination of Benefits (COB) ..................................................................................................... 30
Coordination with Medicare ........................................................................................................... 30
Right of Reimbursement ................................................................................................................31
Subrogation ...................................................................................................................................31
Reimbursement of Common Accident Expenses ........................................................................... 31
Use of Health Information ..............................................................................................................31
Leave of Absence .........................................................................................................................31
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Deluxe Corp.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
Medical Plan – Choice Fund (HRA)
For this plan year, the plan includes the following provisions, subject to change or discontinuation with or without
notice at anytime. This Summary Plan Description presents an overview of your benefits. In the event of any
discrepancy between this Summary Plan Description and the official plan document, the plan document shall
govern.
Your Medical Plan Options
Protecting your health as well as your family’s health is important. That’s why Deluxe offers several medical
coverage options to serve your needs and the needs of your family. By sharing the cost of your medical expenses,
Deluxe helps protect you from the financial uncertainty of major medical expenses.
Your cost for medical coverage is based on the option you elect and whom you elect to cover. The per-pay-period
cost for each option and coverage category is listed on the Your Benefits Resources Web site at
www.ybr.com/deluxe during annual enrollment each year. If you have not provided Your Benefits Resources with
your e-mail address, this information is included in your annual enrollment packet that is mailed to your home in the
fall. During the year, you can access this information through the Your Benefits Resources Customer Care Center
at 1-877-U-ASK-DLX (1-877-827-5359).
Depending on your location, your medical plan choices include CIGNA Choice Fund (HRA), Open Access Plus
(OAP), a regional in-network plan, and Indemnity Plan options. You can view a list of in-network providers in your
area through the Your Benefits Resources Website at http://www.ybr.com/deluxe or by calling the Your Benefits
Resources Customer Care Center at 1-877-U-ASK-DLX (1-877-827-5359). There is no pre-existing condition
clause under any of the medical options.
During the current coverage year, the plan includes the provisions described in this section, subject to any changes
that may occur from time to time. This coverage is available to full-time employees and part-time employees who
are regularly scheduled to work 20 or more hours per week. This does not include seasonal or temporary
employees or independent contractors.
If the Plans Are Ended or Modified
Deluxe reserves the right to amend, modify, suspend, or terminate any of its plans at any time, in whole or in part. If
material changes that affect you are made in the future, you will be notified.
No Implied Promises
Nothing in this Web site says or implies that participation in the plans is a guarantee of continued employment with
the company. Nor is it a guarantee that the plans or contribution levels will remain unchanged in future years.
No Coverage
If you have coverage elsewhere (such as through your spouse’s/domestic partner’s employer), you may not need
coverage through Deluxe.
If you are declining medical coverage for you or you and your dependents, you are able to enroll during the next
annual enrollment. If you experience a qualified change in status, you may call Your Benefits Resources (YBR) at
1-877-U-ASK-DLX (1-877-827-5359) and talk with a YBR Customer Care Specialist to request enrollment within 30
days after your qualified change in status event or your other coverage ends.
In addition, if you gain a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may
be able to enroll yourself and your dependents, provided that you call Your Benefits Resources (YBR) at 1-877-UASK-DLX (1-877-827-5359) and talk with a YBR customer care specialist to request enrollment within 30 days after
the marriage, birth, adoption, or placement for adoption.
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Deluxe Corp.
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Last Updated: Jan 2014
SUMMARY PLAN
DESCRIPTION
MEDICAL – CHOICE FUND HRA
What is Managed Care?
The CIGNA Choice Fund HRA is considered a "managed care" plan. You access care through a network of
doctors, specialists, and hospitals that have agreed to offer their services at negotiated rates to ensure costeffective care. These providers have been carefully screened and approved before being allowed into the network.
The complete list of in-network providers is available to you on the CIGNA Web site at www.cigna.com.
Each time you need medical care you choose an in-network provider or an out-of-network provider.
In-Network
Out-of-Network
Higher benefits level than out-of-network
Reduced benefits level and higher out-of- pocket cost
Your physician or the hospital submits claims for
payment for you
You, your physician, or the hospital submits claims for
reimbursement
If you are unable to locate an In-Network Provider in your area who can provide you with a service or supply that is
covered under this plan, you must call the number on the back of your I.D. card to obtain authorization for Out-ofNetwork Provider coverage. If you obtain authorization for services provided by an Out-of-Network Provider,
benefits for those services will be covered at the In-Network benefit level.
Opportunity to select a Primary Care Physician
This medical plan does not require you to select a primary care physician or to obtain a referral from a primary care
physician to receive all benefits available to you under this plan. However, primary care physicians may be
beneficial in arranging care for you and your dependents.
CIGNA Choice Fund (HRA)
The Consumer Driven Plan puts you in charge of the money you spend for medical care services. With this Plan,
you have flexibility and control in choosing the medical services you and your family members receive — and in
determining how the cost of these services is paid.
The components of the Consumer Driven Plan are:
Health Reimbursement Account (HRA)
As a participant in the Plan, the company will make an annual allocation to your Health Reimbursement Account
(HRA). You can use this account to cover 100% of the cost of covered services, up to the accrued allocation in your
account. Covered services include routine medical services (such as office visits and lab tests). You can also use a
portion of your HRA to pay 100% of the cost (up to the accrued allocation in your account) for services such as a
smoking cessation program or a prescribed weight loss program — that typically are not covered by other medical
plans.
Co-Insurance
In addition to your HRA, the Program offers co-insurance to protect you and your family in case you have significant
medical expenses or your expenses exceed your annual company HRA allocation. This is made available by
Deluxe on a self-insured basis. This coverage takes effect after using your annual company HRA allocation on
covered services and paying your deductible — a specified amount that you must pay out-of-pocket on covered
medical services.
Any day and dollar limits associated with specific benefits under the program will apply under the co-insurance
component.
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Deluxe Corp.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
Additional Features
To help you make the most out of your CIGNA Choice Fund (HRA) coverage — and make the best use of your
health care dollars — you will have access to online tools and resources which will help you make informed
decisions about your health care. You will also have access to the CIGNA 24 hour Health Information Line, support
for chronic conditions for you and eligible family members who may have specific medical conditions, an online
health risk assessment and online coaching programs.
Who is Eligible for the Medical Plan?
You are eligible to receive Deluxe medical coverage if you are:
•
An active, full-time employee;
•
A part-time employee regularly scheduled to work 20 or more hours per week;
•
A Deluxe Qualified Retiree (as outlined by the Qualified Retiree policy) who is under age 65.
This does not include seasonal or temporary employees or independent contractors.
Check with your Human Resources Representative to determine if you are eligible for this plan.
You become eligible for the medical plan on the first day of the month following your date of hire or when you
become otherwise eligible based on your regularly scheduled workweek. You have 30 days to enroll. If you do not
enroll within 30 days, you will default into "No Coverage" and will not be eligible to enroll again until the next annual
enrollment period unless you experience a qualified change in status.
At the time you enroll, you may choose to cover yourself and your eligible dependents.
Eligible Dependents
Your eligible dependents are:
•
Your legally married spouse or domestic partner; and
•
Your children up to age 26, if they are your:
o
Biological children;
o
Legally adopted children;
o
Stepchildren;
o
Foster children;
o
Children who are eligible to be claimed on your income tax return and live with you in a parent-child
relationship at least 50% of the time; or
o
Children for whom you are a legal guardian, as defined by a court order or where a court order
requires medical insurance for the children to be supplied (e.g., through a Qualified Medical Child
Support Order (QMCSO)).
Incapacitated Children
A mentally or physically incapacitated child may continue to be covered beyond the normal age limit. Proof of
incapacitation must be submitted to Your Benefits Resources while your child is covered under a Deluxe provided
plan and before your child reaches the normal age limit and periodically thereafter when requested by your service
provider. You must provide appropriate confirmation when requested in order to continue coverage for your child.
Change Enrollment Elections during Year
You may be eligible to change your enrollment elections during the year if you have a qualified change in status.
spd-medical-choicefundhra-acl.pdf
Deluxe Corp.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
If you gain a new dependent through marriage, the birth of a baby, adoption, or placement for adoption, you must
apply for coverage for the new dependent within 30 days following the event. To enroll your new dependent, you
can talk with a Your Benefits Resources customer care specialist at 1-877-U-ASK-DLX (1-877-827-5359) or enter
your change on-line at www.ybr.com/deluxe. When you add a dependent, spouse or child, to coverage, YBR will
automatically require certification. You will receive a letter requesting documents to certify your dependent’s
eligibility. Documents include marriage certificates, birth certificates, tax returns. Documents must be provided
within 31 days of the enrollment effective date. When documents are received, dependent coverage is activated to
the date of eligibility. If documents are not received and approved by the deadline, your dependents will not be
eligible for coverage until the next annual enrollment or you have another qualified family status event.
If you and/or your dependent(s) were covered under a state Medicaid or CHIP plan and the coverage is terminated
due to a loss of eligibility, you may request enrollment for yourself and any affected dependent(s) who are not
already enrolled in the plan. You must request enrollment within 60 days after termination of Medicaid or CHIP
coverage.
If there is a significant change in cost of benefits or a new benefit option is added during a benefit period, you may
be eligible to elect another available benefit option.
You may be eligible to make a coverage election change if the plan of your spouse or dependent: (a) incurs a
change such as adding or deleting a benefit option; (b) allows election changes due to Special Enrollment, Change
in Status, Court Order, or Medicare or Medicaid eligibility/entitlement; or (c) the plan and the other plan have
different periods of coverage or open enrollment periods.
Qualified Medical Child Support Order (QMCSO)
A Qualified Medical Child Support Order (QMCSO) is a legal order issued by a court or a state agency authorized
under state law that mandates that a specified individual must provide a child with one or both of the following:
•
Financial support; or
•
Health benefit coverage.
If an employee of a participating Deluxe related company is ordered to provide health benefit coverage, the order
must be sent to:
Qualified Order Center
Post Office Box 1433
Lincolnshire, IL 60069-1433
Here is the process that a QMCSO follows:
•
The Qualified Order Center will review the order and determine if it is qualified. If the order is determined
not to be qualified, it will be sent to the employee, beneficiaries, and respective attorney(s) with an
explanation of why it does not qualify.
•
If the order is determined to be qualified, determination letters will be sent to the employee, beneficiaries,
and respective attorney(s).
•
The client and attorney(s) then present the QMCSO to the court for certification.
•
The client sets any necessary payroll deductions or changes.
•
The client and attorney(s) send certification to the Qualified Order Center at the address provided in the
determination letter.
Notification of Qualifying Events that Result in Loss of Coverage
When your qualifying event is the end of employment, reduction of hours of employment or death of the employee,
the Plan will offer COBRA coverage to the qualified beneficiaries. You do not have to notify Your Benefits
Resources (YBR) of any of these three qualifying events as an active employee. It is the responsibility of the
Company to notify Your Benefits Resources (YBR) of these three qualifying events.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
It is your responsibility or the responsibility of your family members to call Your Benefits Resources (YBR) at 1-877U-ASK-DLX (1-877-827-5359) to report a divorce, legal separation, or a child losing dependent status under the
terms of the Plan. A COBRA election will be available to you only if you call Your Benefits Resources (YBR) within
60 days after the later of (1) the date of the qualifying event; and (2) the date on which the qualifying beneficiary
loses, or would lose coverage under the terms of the Plan as a result of the qualifying event.
If you do not call Your Benefits Resources (YBR) to report a qualifying event during the 60-day notice period, you
will lose your right to elect COBRA coverage.
An Overview of Your CIGNA Choice Fund (HRA) Benefits
When you join Deluxe — and each year at annual enrollment — you choose the medical plan that best fits the
needs of you and your family. Your decision remains in effect for one calendar year, unless you experience a
qualified change in status that changes your coverage needs. At that time, you may be able to change your original
benefit elections. Call Your Benefits Resources (YBR) at 1-877-U-ASK-DLX (1-877-827-5359) within 30 days of the
qualified change in status and talk with a YBR customer care specialist to request a change to your coverage if
necessary.
Under the Deluxe health plans, benefits you receive for certain medical services and supplies have specific
limitations or are paid at predetermined levels. The following highlights the benefits for these expenses.
Premium Payments or Fees to Purchase Coverage
You and Deluxe pay the cost of your medical care. As medical care costs increase, the Deluxe contribution and
your employee contribution are adjusted. This means that as the cost of medical care increases, you will pay more
toward your premiums.
Deluxe provides flexible credits of a specified dollar amount to use toward the purchase of medical coverage, and
you pay the difference. Medical plan credits are determined based on whom you decide to cover: yourself, your
spouse or domestic partner, and your family.
Annual Deductible
Your annual deduction is a combination of Your HRA and Your Share. Once you meet the annual deductible you
pay a co-insurance for your eligible expenses and the plan pays the rest.
Your HRA
Deluxe makes an annual allocation to a Health Reimbursement Account (HRA) set up in your name. You can use
your HRA to pay the cost of routine medical expenses like office visits and lab tests, and covered services above
the maximum reimbursable amount or co-insurance you incur in your co-insurance.
The HRA is only available for IRC Section 213 Qualified Medical Expenses that are covered under the benefit plan.
You can never take an amount out of the HRA in cash for other than benefits covered under the program.
Any HRA amounts that you use to cover expenses above the maximum reimbursable amount or for services
beyond the annual benefit maximums will not count toward your annual out-of-pocket maximum.
Your Share
When you have eligible medical claims, they are first paid from Your HRA. If your annual Company allocation to
your HRA is depleted, you will pay up to the amount listed in the chart below. This is called Your Share. Your Share
for employee + spouse, employee + children, or employee + family coverage can be satisfied by a single family
member or by eligible expenses incurred by a combination of family members. An individual cannot have claims
covered under the plan co-insurance until the total employee + spouse/child or family deductible has been satisfied.
If you have been in the CIGNA Choice Fund (HRA) plan for more than one year, you may have a balance from an
earlier plan year in Your HRA. This balance may be used to satisfy all or a portion of Your Share, which will reduce
the amount you pay out-of-pocket.
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SUMMARY PLAN
DESCRIPTION
MEDICAL – CHOICE FUND HRA
Your Annual Deductible - Combination of Your HRA and Your Share
In-Network
Out-of-Network
Employee
$1,250
$1,750
Employee + Spouse
$1,875
$2,625
Employee + Child(ren)
$1,875
$2,625
Employee + family
$2,500
$3,500
Your HRA - Funded by Deluxe
Corporation
Your Share – deductible paid by you once you use up the money in
your HRA
In-Network
Out-of-Network
Employee
$625
Employee
$625
$1,125
Employee + Spouse
$938
Employee + Spouse
$937
$1,687
Employee + Child(ren)
$938
Employee + Child(ren)
$937
$1,687
Employee + Family
$1250
Employee + family
$1,250
$2,250
If you do not use the full amount of your HRA each plan year, it will be rolled over for your use in the next plan year.
If you experience a change in family status during the plan year that results in a reduction from family to individual
coverage, your HRA allocation will not change until the beginning of the next plan year. If the change in family
status results in an increase from individual to family coverage, you will receive an additional HRA allocation equal
to the difference between the individual and family allocation. If your participation in the Program ends for any
reason, any balance in your HRA will be forfeited.
Co-Insurance
If your expenses exceed your annual deductible, which includes using the entire annual company HRA allocation
on covered expenses and paying Your Share, the co-insurance portion will begin. This protects you and your family
in case you incur significant medical expenses. You pay a percentage of the cost of your medical expenses and the
plan pays the rest. Your co-insurance amount depends on your use of providers that are in-network or out-ofnetwork.
Your Co-Insurance
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In-Network
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Out-of-Network
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SUMMARY PLAN
DESCRIPTION
MEDICAL – CHOICE FUND HRA
You Pay
20%
40%
Plan Pays
80%
60% of Maximum Reimbursable Charge
Annual Out-of-Pocket Maximum Amounts
When you meet your out-of-pocket maximum, your plan pays 100% of covered expenses for network providers and
100% of maximum reimbursable charges for out-of-network providers. Your out-of-pocket maximum is the sum of
your annual deductible and co-insurance. All employee + spouse/child or family members contribute toward the
employee + spouse/child or family out-of-pocket. An individual cannot have claims covered at 100% until the total
employee + spouse/child or family out-of-pocket has been satisfied.
Your Annual Out-of-Pocket Maximum
In-Network
Out-of-Network
Employee
$3,500
$5,700
Employee + Spouse
$5,250
$8,550
Employee + Child(ren)
$5,250
$8,550
Employee + family
$7,000
$11,400
Because you can use part of your HRA to pay for certain medical expenses that are not covered by the CIGNA
Choice Fund (HRA) plan, the amount you pay out of your own pocket toward the annual out-of-pocket maximum
each year can vary from year-to-year. The more you use your HRA on covered services, the less you will have to
pay out of your own pocket toward your annual out-of-pocket maximum.
IMPORTANT! Amounts you pay toward the cost of medical expenses that are not covered by the CIGNA Choice
Fund (HRA) plan will not count toward your annual out-of-pocket maximum. These include costs you pay for:
•
Active, COBRA, or retiree premiums;
•
Medical expenses that are in excess of maximum reimbursable charges; and
•
Medical expenses that are in excess of annual maximums
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Deluxe Corp.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
Additional Features
Online Health Risk Assessment
Within 10 business days of completion of the online health risk assessment, a $50 additional allocation will be
credited to your HRA Fund. You are allowed one annual allocation reward per HRA account.
Online Coaching Programs
Up to $40 can be added to your HRA upon completion of 4 online coaching programs, $10 for each program. The
programs run for 6-8 weeks and include topics such as coping with stress, boosting energy levels, weight loss, and
sleeping better. After registering, you will receive emails with tasks to complete, which will be tracked online. Once
a program has been completed, a deposit will be credited to your HRA within 10 business days.
Coaching Support for Chronic Conditions
$100 can be credited to your HRA upon completion of a disease management program through Well Aware for
Better Health. If you have a chronic condition such as asthma, low back pain, cardiac, chronic obstructive
pulmonary disease, diabetes, or depression you may be eligible. Credit will be applied to your HRA within 6-8
weeks of completing the program. Credit is provided for the completion of one disease management program per
HRA account.
HRA Extras
In addition to using your HRA allocation to pay for the types of medical expenses defined as covered under your
co-insurance, you can use it to cover the cost of certain qualified medical care expenses not usually covered by
traditional medical plans.
Qualified medical expenses are defined under section 213 of the Internal Revenue Code as: Services provided for
the diagnosis, cure, mitigation, treatment, or prevention of disease, and for treatments affecting any part or function
of the body. The medical care expenses must be primarily to alleviate or prevent a physical or mental defect or
illness. Eligible expenses include:
•
Premiums for Cobra Coverage
•
Post- tax premiums for Retiree Benefits
IMPORTANT! If you use your HRA allocation on additional features as outlined above, you have to make up the
difference of the expense (either out-of-pocket or from a previous Plan year's HRA savings) if you require additional
services through co-insurance.
Covered Services under the Medical Plan
For expenses to be covered under the CIGNA Choice Fund HRA, they must be:
•
Incurred after you or your affected dependent(s) becomes insured for these benefits;
•
Recommended by a physician;
•
For the treatment of an illness or injury;
•
Medically necessary in light of generally accepted medical standards; and
•
Within the maximum reimbursable charge amount.
The Maximum Reimbursable Charge is subject to all other benefits limitations and applicable coding and payment
methodologies determined by CIGNA Group.
CIGNA determines whether expenses you submit meet the above criteria. The determination of whether an
expense is medically necessary is based on, and consistent with, standards used by CIGNA.
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SUMMARY PLAN
DESCRIPTION
MEDICAL – CHOICE FUND HRA
Please note that a procedure or treatment is not considered medically necessary just because a physician has
performed or prescribed it, or because the procedure or treatment is the only treatment for a particular injury,
illness, or mental illness. A determination by your insurance carrier that a service or supply is not medically
necessary may apply to the entire service or supply or to any part of it.
BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Maximum Reimbursable Charge
Not applicable
200%
Primary Care Physician's Office visit
80% after plan deductible
60% after plan deductible
Specialty Care Physician's Office Visit
80% after plan deductible
60% after plan deductible
Surgery Performed In the Physician's Office
80% after plan deductible
60% after plan deductible
Second Opinion Consultations (services will be
provided on a voluntary basis)
80% after plan deductible
60% after plan deductible
Allergy Treatment/Injections
80% after plan deductible
60% after plan deductible
Allergy Serum (dispensed by the physician in the
office)
80% after plan deductible
60% after plan deductible
Maximum reimbursable charge is determined based
on the lesser of the provider's normal charge for a
similar service or supply; or
• A percentage of a fee schedule developed by
CIGNA that is based upon a methodology similar
to methodology utilized by Medicare to determine
the allowable fee for the same or similar service
within the geographic market.
In some cases, a Medicare based fee schedule will
not be used and the Maximum reimbursable charge
for covered services is determined based on the
lesser of:
• the provider’s normal charge for a similar service
or supply; or
• the charges made by 80% of the providers of
such service or supply in the geographic area
where it is received as compiled in a database
selected by CIGNA.
Note: The provider may bill you for the difference
between the provider’s normal charge and the
maximum reimbursable charge, in addition to
applicable deductibles, copayments and coinsurance.
Physician's Services
Office Visits
Consultant and Referral Physician's Services
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MEDICAL – CHOICE FUND HRA
BENEFIT HIGHLIGHTS
Preventive Care
Routine Preventive Care – Well Baby, Well-child
and Adult Preventive Care (Includes school
physician exam)
Immunizations (Includes Immunization for travel
aboard)
Mammograms, PSA, Pap Smear
IN-NETWORK
100%, no plan deductible
SUMMARY PLAN
DESCRIPTION
OUT-OF-NETWORK
Covered In-Network only
Note:
− As there is no member
responsibility, charges
are not withdrawn from
the Choice Fund.
− Preventative Care
related Xray and lab
services billed by a
physician’s office, a
separate outpatient
diagnostic facility such
as an outpatient hospital
facility or independent
facility will be covered at
100%; no deductible.
100%, no plan deductible
Routine Preventive
100%, no plan deductible
Covered In-Network only
Medically Necessary Diagnostic Related Services
80% after plan deductible
60% after plan deductible
80% after plan deductible
60% after plan deductible
Semi Private Room and Board
Limited to semi-private
room negotiated rate
Limited to semi-private room
rate
Private Room
Limited to semi-private
room negotiated rate
Limited to semi-private room
rate
Special Care Units (ICU/CCU)
Limited to negotiated rate
Inpatient Hospital - Facility Services
Outpatient Facility Services
Operating Room, Recovery Room, Procedures
Room, Treatment Room and Observation Room
80% after plan deductible
Limited ICU/CCU daily room
rate
60% after plan deductible
Inpatient Hospital Physician’s
Visits/Consultations
Inpatient Hospital Professional Services
80% after plan deductible
60% after plan deductible
80% after plan deductible
60% after plan deductible
Surgeon, Radiologist, Pathologist,
Anesthesiologist
Multiple Surgical Reduction
Multiple surgeries performed during one operating session
result in payment reduction of 50% of charges to the
surgery of lesser charge. The most expensive procedure
is paid as any other surgery.
Outpatient Professional Services
Surgeon, Radiologist, Pathologist,
Anesthesiologist
80% after plan deductible
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60% after plan deductible
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MEDICAL – CHOICE FUND HRA
BENEFIT HIGHLIGHTS
Emergency and Urgent Care Services
Ambulance
Inpatient Services at Other Health Care Facilities
Includes Skilled Nursing Facility, Rehabilitation
Hospital and Sub-Acute Facilities
(Subject to medical necessity and not covered
when the facility is the member's primary
residence)
IN-NETWORK
SUMMARY PLAN
DESCRIPTION
OUT-OF-NETWORK
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
60% after plan deductible
80% after plan deductible
60% after plan deductible
Outpatient Hospital Facility
80% after plan deductible
60% after plan deductible
Emergency Room/Urgent Care Facility (billed by
the facility as part of the ER/UC visit)
80% after plan deductible
80% after plan deductible
Independent X-ray and/or Lab Facility
80% after plan deductible
60% after plan deductible
Independent X-ray and/or Lab Facility in
conjunction with an ER visit
80% after plan deductible
80% after plan deductible
80% after plan deductible
60% after plan deductible
Outpatient Facility
80% after plan deductible
60% after plan deductible
Emergency Room/Urgent Care Facility (billed by
the facility as part of the ER visit)
80% after plan deductible
80% after plan deductible
Physician's Office
80% after plan deductible
60% after plan deductible
80% after plan deductible
60% after plan deductible
Cardiac Rehabilitation
Limited to 36 days per calendar year
80% after plan deductible
60% after plan deductible
Chiropractic Services
24 days maximum per calendar year
80% after plan deductible
60% after plan deductible
Home Health Care
60 days maximum per calendar year (includes
outpatient private duty nursing when approved as
medically necessary)
80% after plan deductible
60% after plan deductible
90 100 days combined maximum per calendar
year
Laboratory and Radiology Services
(includes pre-admission testing)
Physician’s Office
Advanced Radiological Imaging
(i.e. MRI’s, MRAs CAT Scans, PET Scans, etc.)
Inpatient Facility
Outpatient Short-Term Rehabilitative Therapy
60 days combined maximum per calendar year
Includes:
Physical Therapy
Restorative Speech Therapy
Occupational Therapy
Pulmonary Rehab
Cognitive Therapy
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BENEFIT HIGHLIGHTS
IN-NETWORK
SUMMARY PLAN
DESCRIPTION
OUT-OF-NETWORK
Hospice
Inpatient Services
80% after plan deductible
60% after plan deductible
Outpatient Services
80% after plan deductible
60% after plan deductible
Inpatient
80% after plan deductible
60% after plan deductible
Outpatient
80% after plan deductible
60% after plan deductible
Initial Visit to Confirm Pregnancy
80% after plan deductible
60% after plan deductible
All Subsequent Prenatal Visits, Postnatal Visits,
and Physician’s Delivery Charges (i.e. global
maternity fee)
80% after plan deductible
60% after plan deductible
Office Visits in addition to the global maternity fee
when performed by an OB or Specialist.
80% after plan deductible
60% after plan deductible
Delivery – Facility (Inpatient Hospital, Birthing
Center)
80% after plan deductible
60% after plan deductible
Bereavement Counseling
Maternity Care Services
Abortion
Covers non-elective procedures only
Family Planning Services
Office Visits, Test and Counseling
Note: Coverage is included for contraceptive devices
(e.g. Depo-Provera and Intrauterine Devices (IUDs).
Diaphragms will also be covered when services are
provided in the physician’s office.)
Organ Transplant
Includes all medically appropriate,
non-experimental transplants
Inpatient Facility
Physician’s Services
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80% after plan deductible
80% after plan deductible
60% after plan deductible
60% after plan deductible
100% after plan deductible 60% after plan deductible
at Lifesource center;
otherwise 80% after plan
deductible
100% after plan deductible
at Lifesource center;
otherwise 80% after plan
deductible
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60% after plan deductible
Out-of-network transplant
services will be subject to the
following maximums:
Heart - $150,000
Liver - $230,000
Bone Marrow - $130,000
Heart/Lung - $185,000
Lung - $185,000
Pancreas - $50,000
Kidney - $80,000
Kidney/Pancreas - $80,000
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MEDICAL – CHOICE FUND HRA
BENEFIT HIGHLIGHTS
IN-NETWORK
SUMMARY PLAN
DESCRIPTION
OUT-OF-NETWORK
Lifetime Travel Services Maximum- only available
for Lifesource facilities
Durable Medical Equipment
External Prosthetic Appliances
Dental Care
$10,000
In-network coverage only
80% after plan deductible
80% after plan deductible
60% after plan deductible
60% after plan deductible
Limited to charges made for a continuous course of
dental treatment started within six months of an injury
to sound, natural teeth.
80% after plan deductible
60% after plan deductible
Bariatric Surgery
Treatment of clinically severe obesity, as defined by
the body mass index (BMI) is covered only at
approved centers.
80% after plan deductible
Covered In-network only
The following are excluded:
−
Medical and surgical services to alter
appearances or physical changes that are the
result of any surgery performed for the
management of obesity or clinically severe
(morbid) obesity.
−
Weight loss programs or treatments, whether
prescribed or recommended by a physician or
under medical supervision.
TMJ - Surgical and Non-surgical
Not Covered
Not Covered
Routine Foot Disorders
Not covered, except for
services associated with
foot care for diabetes and
peripheral vascular
disease, when medically
necessary.
Not covered, except for
services associated with foot
care for diabetes and
peripheral vascular disease,
when medically necessary
Mental Health & Substance Abuse (Alcohol &
Drugs)
Inpatient
80% after plan deductible
60% after plan deductible
Outpatient (Includes Individual, Group and
Intensive Outpatient)
Physician’s Office
80% after plan deductible
60% after plan deductible
Outpatient Facility
80% after plan deductible
60% after plan deductible
Substance Abuse (Alcohol & Drugs)
Inpatient
80% after plan deductible
60% after plan deductible
Outpatient (Includes Individual and Intensive
Outpatient)
Physician’s Office
80% after plan deductible
60% after plan deductible
Outpatient Facility
80% after plan deductible
60% after plan deductible
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SUMMARY PLAN
DESCRIPTION
MEDICAL – CHOICE FUND HRA
Hospital Expenses (Inpatient and Outpatient)
• Room and board at the semiprivate room rate.
•
Intensive care and cardiac care at negotiated rate.
•
Miscellaneous medically necessary services and supplies while confined in the hospital.
•
Hospital outpatient treatment services and supplies for illness, injury, or outpatient surgery.
Surgical Services
• Inpatient and outpatient surgery performed by a physician.
•
Free-standing surgical facility for medical care and treatment.
•
Active services of an assisting surgeon not to exceed 20% of the surgeon’s allowable charge prior to any
reductions due to deductible or coinsurance amounts.
•
Active services of a co-surgeon not to exceed 62.5% of the surgeon’s allowable charge prior to any
reductions due to deductible or coinsurance amounts.
•
Anesthetics and their administration by a physician or professional anesthetist not employed by the
hospital.
•
Coverage is provided for an opinion provided by a second physician, when one physician recommends
surgery to an individual.
•
Reconstructive breast surgery following a medically necessary mastectomy. Consistent with the Women's
Health and Cancer Rights Act, if you have a mastectomy and elect reconstructive surgery in connection
with the mastectomy, coverage is provided for:
o
Reconstruction of the breast on which the mastectomy was performed;
o
Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
o
Prosthesis and physical complications for all stages of the mastectomy, including lymphedemas.
When two or more surgical procedures are performed at one time, the maximum amount payable is the amount
otherwise payable for the most expensive procedure and one-half of the amount payable for all other surgical
procedures.
Medical Services
• Professional services provided by a licensed physician or psychologist.
•
Professional services provided by a nurse.
•
Ambulance service when emergency transportation is required.
•
Blood transfusions and blood not donated or replaced.
•
Medically necessary diagnostic X-rays in conjunction with the treatment of illness or injury.
•
X-rays, radium, and radioactive isotope treatment.
•
Chemotherapy.
•
Rental or purchase (if approved by the health plan provider) of durable medical equipment.
•
Therapy provided by a licensed physical, occupational, or speech therapist.
•
Prosthetic appliances.
•
Dressings.
•
Air ambulance when emergency transportation is required and ground transportation is not appropriate due
to distance or if unstable patient requires rapid transportation. Notification is required except in life
threatening circumstances.
•
Emergency services and urgent care.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
Transplant Surgery
Charges made for human organ and tissue transplant services which include solid organ and bone marrow/stem
cell procedures at designated facilities throughout the United States or its territories. This coverage is subject to
certain conditions and limitations.
•
Immunosuppressive medication.
•
Organ procurement costs.
•
Donor’s medical costs, reduced by the amount payable for those costs from any other plan.
See CIGNA LIFESOURCE Organ Transplant Network for more information.
Home Health Care
• Part-time or intermittent nursing care by or under the supervision of a registered graduate nurse (R.N.).
•
Part-time or intermittent services of a home health aide.
•
Physical, occupational, or speech therapy.
•
Medical supplies and medicines lawfully dispensed on the written prescription of a physician and laboratory
services; but only to the extent they would have been covered if the patient had been confined in a hospital
or a skilled nursing facility.
•
If patient is dependent on others for non-skilled care (i.e. bathing, eating), home health care services will
only be provided when non-skilled care provider is present to meet those needs.
•
Home health care visits are limited to 60 per calendar year.
Hospice Care
• Room and board at the semiprivate room rate.
•
Medically necessary services and supplies while confined in the hospice facility.
•
Facility services and supplies for treatment on an outpatient basis.
•
Medical services, consultation, or case management services provided by a physician.
•
Individual and family counseling provided by a psychologist, social worker, family counselor, or ordained
minister. This includes bereavement counseling within one year after the person's death.
•
Pain relief treatment, including drugs, medicines, and medicinal supplies.
•
Home health care services:
o
Part-time or intermittent nursing care by or under the supervision of a registered graduate nurse
(R.N.);
o
Part-time or intermittent services of a home health aide;
o
Physical, occupational, and speech therapy; and
o
Medical supplies and medicines lawfully dispensed on the written prescription of a physician and
laboratory services; but only to the extent they would have been covered if the patient had been
confined in a hospital or hospice facility.
Chiropractic Care
• Limited to the management of disability of the spine, neck, and muscular ligamentous attachments of that
organ system.
•
Medically necessary care provided in an office setting:
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MEDICAL – CHOICE FUND HRA
o
Physical examination, including patient history;
o
Spinal X-rays;
o
Laboratory tests; and
o
Neuromuscular treatment and manipulation.
•
Limited to acute conditions only.
•
Limited to 24 days per calendar year
SUMMARY PLAN
DESCRIPTION
Foreign Claims
Foreign claims are covered at the out of network level, based on the Foreign Exchange Rate as of the date of
service, and paid to the employee.
Dental Services and Oral Surgery
Charges for care rendered by a physician or dentist, which are required as a result of an accidental injury to the
jaws, sound natural teeth, mouth or face, provided care commences within six months of injury to sound, natural
teeth. Injury as result of chewing or biting will not be considered an accidental injury.
Charges for surgical benefits for cutting procedures for the treatment of disease, injuries, fractures and dislocation
to the jaw when the service is performed by a physician or dentist are also considered covered services.
Clinical Trials
• Charges made for routine patient services associated with cancer clinical trials approved and sponsored by
the federal government. In addition, the following criteria must be met:
•
o
The cancer clinical trial is listed on the NIH web site www.clinicaltrials.gov as being sponsored by
the federal government;
o
The trial investigates a treatment for cancer and; (1) the person has failed standard therapies for
the disease; (2) cannot tolerate standard therapies for the disease; or (3) no effective nonexperimental treatment for the disease exists;
o
The person meets all inclusion criteria for the clinical trial and is not treated “off-protocol”
o
The trial is approved by the Institutional Review Board of the institution administering the treatment;
and
o
Coverage will not be extended to clinical trials conducted at nonparticipating facilities if a person is
eligible to participate in a covered clinical trial from a participating provider.
Coverage does not include reimbursement for:
o
The investigational service or supply itself;
o
Service or supplies related to data collection for the clinical trial;
o
Services or supplies which, in the absence of private health care coverage, are provided by a
clinical trial sponsor or other party without charge to the trial participant.
Genetic Testing
• Charges made for genetic testing that uses a proven testing method for the identification of geneticallylinked inheritable disease. Genetic testing is covered only if:
o
A person has symptoms or signs of a genetically-linked inheritable disease;
o
It has been determined that a person is at risk for carrier status as supported by existing peerreviewed, evidence-based, scientific literature for the development of a genetically-linked
inheritable disease when the results will impact clinical outcomes; or
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MEDICAL – CHOICE FUND HRA
o
•
SUMMARY PLAN
DESCRIPTION
The therapeutic purpose is to identify specific genetic mutation that has been demonstrated in the
existing peer-reviewed, evidence-based, scientific literature to directly impact treatment options.
Genetic counseling is covered if a person is undergoing approved genetic testing, or if a person has an
inherited disease and is a potential candidate for genetic testing.
o
Limited to 3 visits per calendar year for both pre- and post-genetic testing.
Services Not Covered Under the Medical Plan
There are some expenses that are not covered under the CIGNA Choice Fund plan.
Non-covered General Medical Services
• Injury or illness arising out of any employment that is covered under any Workers' Compensation or similar
law.
•
Care for health conditions that are required by state or local law to be treated in a public facility.
•
Care required by state or federal law to be supplied by a public school system or school district.
•
Care for military service disabilities treatable through governmental services if you are legally entitled to
such treatment and facilities are reasonably available.
•
Expenses resulting from active participation in a riot or commission of a crime or war.
•
Expenses for supplies, care, treatment, or surgery that are not medically necessary.
•
Charges made by an assistant surgeon in excess of 20% of the surgeon's allowable charge, or for charges
made by a co-surgeon in excess of 62.5% of the surgeon's allowable charge.
•
Inpatient treatment or confinement for weight reduction, as well as eating disorders such as anorexia
nervosa and bulimia nervosa, unless medically necessary.
•
Nonmedical equipment used in the home, such as humidifiers, dehumidifiers, dust precipitators, air
conditioners, water purifiers, allergenic mattresses or supplies, or exercise equipment.
•
Expenses for or in conjunction with in vitro fertilization, artificial insemination, or similar procedures.
•
Infertility treatments (procedures and medications) to affect a pregnancy by extraordinary means.
•
Elective abortions.
•
Expenses for or in connection with experimental procedures or treatment methods not approved by the
American Medical Association or the appropriate medical specialty society.
•
Rhinoplasty; Blepharoplasty; Acupressure; Dance therapy, movement therapy; Applied kinesiology;
Rolfing; and Extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.
•
Charges for experimental drugs or substances not approved by the Food and Drug Administration, or for
drugs labeled "Caution - limited by federal law to investigational use."
•
Charges for drugs available over-the-counter that do not require a prescription by federal or state law.
•
Charges for any drug that is a pharmaceutical alternative to an over-the-counter drug other than insulin.
•
Normal foot care for treatment of tired, weak, or strained feet, unless medically necessary, including but not
limited to the removal of calluses and corns, and the trimming of nails.
•
Chiropractic charges for maintenance or preventive care, or for chronic conditions.
•
Expenses for or in connection with speech therapy, if such therapy is used to improve speech skills that
have not fully developed, can be considered custodial or educational, or is intended to maintain speech
communication. Speech therapy that is not restorative in nature is not covered.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
•
Charges made by any covered provider who is a member of your family or your dependent's family.
•
Charges for medical and surgical services intended primarily for the treatment or control of obesity which
are not Medically Necessary.
•
Reports, evaluations, physical examinations, or hospitalization not required for health reasons, including
but not limited to employment, insurance or government licenses, and court ordered, forensic, or custodial
evaluations.
•
Court ordered treatment or hospitalization, unless such treatment is being sought by a Participating
Physician.
•
Reversal of male and female voluntary sterilization procedures.
•
Transsexual surgery, including medical or psychological counseling and hormonal therapy in preparation
for, or subsequent to, any such surgery.
•
Any services, supplies, medications or drugs for the treatment of male or female sexual dysfunction such
as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmia, and
premature ejaculation.
•
Therapy or treatment intended primarily to improve or maintain general physical condition or for the
purpose of enhancing job, school, athletic or recreational performance, including, but not limited to routine,
long-term or maintenance care which is provided after the resolution of the acute medical problem and
when significant therapeutic improvement is not expected.
•
Private hospital rooms.
•
Personal or comfort items such as personal care kits provided on admission to a hospital, television,
telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles
which are not for the specific treatment of illness or injury.
•
Artificial aids, including but not limited to corrective orthopedic shoes, arch supports, elastic stockings,
garter belts, corsets, dentures and wigs.
•
Aids or devices that assist with non-verbal communications, including, but not limited to communication
boards, pre-recorded speech devices, laptop computers, desktop computers, Personal Digital Assistants
(PDAs), Braille typewriters, visual alert systems for the deaf and memory books.
•
Treatment by acupuncture.
•
Membership costs or fees associated with health clubs, weight loss programs and smoking cessation
programs.
•
Genetic screening or pre-implantation genetic screening.
•
Amniocentesis, ultrasound, or any other procedures requested solely for sex determination of a fetus,
unless medically necessary to determine the existence of a sex-linked genetic disorder.
•
Dental implants for any condition.
•
Fees associated with the collection or donation of blood or blood products, except for autologous donation
in anticipation of scheduled services where in the Healthplan Medical Director’s opinion the likelihood of
excess blood loss is such that transfusion is an expected adjunct to surgery.
•
Blood administration for the purpose of general improvement in physical condition.
•
Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against
occupational hazards and risks.
•
Cosmetics, dietary supplements and health and beauty aids.
•
All nutritional supplements and formulae are excluded, except for infant formula needed for the treatment of
inborn errors of metabolism.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
•
Expenses incurred for medical treatment by a person age 65 or older, who is covered under this
Agreement as a retiree, or his Dependents, when payment is denied by the Medicare plan because
treatment was not received from a Participating Provider of the Medicare plan.
•
Expenses incurred for medical treatment when payment is denied by the Primary Plan because treatment
was not received from a Participating Provider of the Primary Plan.
•
Telephone, e-mail & Internet consultations and telemedicine.
•
Massage Therapy.
•
Certain internal or external prostheses, or replacement of external prostheses due to wear and tear, loss,
theft or destruction.
•
Cosmetic surgery, unless the covered person incurs an injury that requires the surgery; or the cosmetic
surgery is necessary to restore impaired bodily function resulting from disease, genetic abnormality, or
previous therapeutic processes. Reconstructive surgery for the correction of congenital birth defects or
developmental abnormalities must be performed prior to your attainment of age 19 to be covered under this
medical plan.
•
The fitting and cost of hearing aids.
•
Routine eye examinations or eye refractions performed in conjunction with routine eye examinations.
•
The fitting and cost of eyeglasses or contact lenses. (The first pair of eyeglasses or contact lenses is
covered only when required as the result of cataract surgery.)
•
Dental work, oral appliances, or oral surgery unless charges are made for or in connection with dental work
due to an injury to sound, natural teeth provided treatment begins within 6 months of injury.
•
Expenses for or in connection with custodial services, education, or training.
•
Expenses in excess of maximum reimbursable amounts.
•
Charges that the person is not legally required to pay.
•
Charges that would not have been made if the person had no insurance.
•
Charges for unnecessary care, treatment, or surgery, except as specified in any certification requirement.
•
Immunizations required for school.
•
If you have coverage under the Open Access Plus, preventive services (e.g., physicals or immunizations)
are not covered if received from an out-of-network service provider.
•
Surgical or non-surgical treatment of TMJ.
•
Charges for assistance in the activities of daily living, including but not limited to eating, bathing, dressing
or other custodial services or self-care activities.
•
Treatment of disorders which have been diagnosed as organic mental disorders associated with permanent
dysfunction of the brain.
•
Treatment of developmental disorders.
•
Psychological testing on children requested by or for a school system.
Non-covered Home Health Care Services
• Home health care visits that exceed the limit of 60 visits per calendar year.
•
Care or treatment that is not specifically stated as covered under home health care benefits.
•
Services performed by a person who is a member of your family or your dependent's family or who
normally lives in your home or your dependent's home.
•
Charges incurred during a period when a person is not under the continuing care of a physician.
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MEDICAL – CHOICE FUND HRA
•
SUMMARY PLAN
DESCRIPTION
Transportation of a social worker.
Non-covered Hospice Care Services
• Services performed by a person who is a member of your family or your dependent's family or who
normally lives in your home or your dependent's home.
•
Charges incurred during a period of time when you or your dependent is not under the continuing care of a
physician.
•
Services or supplies that are not listed under hospice care benefits.
•
Curative or life-prolonging procedures.
•
Services or supplies that are primarily to aid you or your dependent in daily living.
Pre-Authorization Certification for Services and Continued Stay Review for Inpatient Care
To help assure that your treatment is medically necessary under the terms of your medical plan, CIGNA has
partnered with a review organization to provide admission and concurrent review of inpatient admission for hospital
(medical and surgical), rehabilitation, skilled nursing facility, detoxification facility, and mental health and substance
abuse residential treatment centers. The review organization also reviews and pre-authorizes services such as
transplant services, advanced radiological imaging – CT Scans, MRI, MRA, or Pet Scans, nonemergency
ambulance, and hysterectomy services. These are not all-inclusive lists. To validate the necessity for preauthorization, call CIGNA prior to services being rendered.
How Do I Start the Precertification Process?
To start the precertification process, you must call CIGNA at 1-800-CIGNA-24 (1-800-244-6224) before an elective
hospital admission, or in the case of an emergency admission, you must call by the end of the second business day
after the admission.
To pre-certify a hospital admission due to pregnancy for you (or your dependent), call CIGNA by the end of the third
month of pregnancy.
CIGNA monitors your confinement until you are discharged from the hospital.
To pre-certify all other services listed above, you must call CIGNA before obtaining services.
What Happens if I Do not Pre-certify?
If you do not obtain pre-authorization approval prior to incurring covered expense, benefits paid by the plan for the
covered expenses will be reduced by 20% for all treatment, supplies, and services.
If you do not call, or if you are not certified for admission, benefits for the following hospital charges are reduced by
20%.
•
Any charges for a hospitalization unless preadmission certification is received:
o
Prior to the date of admission; or
o
In the case of an emergency admission, by the end of the second business day after the
admission.
•
Hospital room and board charges for hospital services that have been certified, but exceed the certified
number of days.
•
Any charges for a hospitalization where preadmission certification was requested, but which was not
certified as medically necessary.
Expenses incurred for which payment is excluded by the terms set forth above will not be considered as expenses
incurred for the purpose of any other part of this plan, except for the “Coordination of Benefits” section.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
Maternity Hospital Stays
Consistent with the Newborns’ and Mothers’ Health Protection Act, the plan does not restrict benefits for any
hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a
normal vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain
authorization from the plan for prescribing a length of stay not in excess of the above periods.
Nursery charges, other hospital services and supplies and physician’s charges for hospital visits for healthy
newborn children will be covered under the mother’s benefit.
Newborn children will be considered a dependent under the Plan immediately following birth until discharged from
the hospital or 7 days old, whichever comes first. If the member wishes to continue coverage for the newborn
beyond that date, the member must call Your Benefits Resources (YBR) within 30 days of the baby’s birth and talk
with a Your Benefits Resources Customer Care Specialist to request enrollment of the baby in the member’s
medical plan. If the baby is not enrolled in the member’s medical plan within 30 days after birth, the baby will not be
eligible for coverage under the member’s medical plan until the next plan year or the member has another qualified
status change.
Prescription Drug Coverage
If you elect the Choice Fund (HRA), you can receive prescription drug services through a retail pharmacy for shortterm or non-maintenance prescriptions or through mail order services for ongoing, maintenance prescriptions. The
prescription drug program is described in the following sections of this Web site.
Retail Pharmacy Program
If you have medical coverage under the Choice Fund (HRA), you will use the CIGNA Tel-Drug Retail Pharmacy
Program for covered prescriptions that you need immediately or will take for no longer than 30 days. As with
medical coverage, to get the best value out of your prescription drug benefits, you should go to a network pharmacy
for your immediate or short-term prescription drugs.
Under the Choice Fund (HRA) program, your pharmacy costs will be based on where you are within your benefit
plan. While you have money in the HRA, you will not pay for any covered prescription drugs at the pharmacy. The
cost of the prescription will be deducted from your HRA. When you are in Your Share, you will pay the discounted
cost of the covered drug. Once you reach the Co-Insurance, you pay 20% coinsurance for prescriptions filled at innetwork pharmacies. You pay 40% coinsurance for out-of-network pharmacies and for foreign claims. When you
receive your prescription from a pharmacy, you are able to get up to a 30-day supply.
For a list of participating pharmacies, contact a CIGNA Tel-Drug representative at 1-800-285-4812.
Mail Order Program
If you are covered under the Choice Fund (HRA) and take medication on an ongoing basis or for 31 to 90 days, you
must order your covered prescriptions by mail. Ordering maintenance prescription drugs by mail is convenient and
allows for larger refill sizes, generally 90 days at a time. This is how it works:
Your pharmacy costs will be based on where you are within your benefit plan. While you have money in the HRA,
you will not pay for any covered prescription drugs at the pharmacy. The cost of the prescription will be deducted
from your HRA. When you are in Your Share, you pay the discounted cost of the covered drug. Once you reach the
Co-Insurance, you pay 20% coinsurance for in-network pharmacies. Out-of-network mail order pharmacies are not
covered.
Coverage for up to two fills may be provided at a retail pharmacy for each maintenance drug. The third prescription
must be filled through the mail-order program.
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To learn more information about the mail order program, you may log on to www.mycigna.com. To talk with a
CIGNA Tel-Drug representative, call 1-800-285-4812.
Step Therapy
Coverage for certain prescription drugs and related supplies requires your physician to obtain authorization prior to
prescribing. Prior authorization may include, for example, a step therapy determination. Step therapy determines
the specific usage progression of therapeutically equivalent drug products or supplies appropriate for treatment of a
specific condition. If your physician wishes to request coverage for prescription drugs or related supplies for which
prior authorization is required, your physician may call or complete the appropriate prior authorization form and fax
it to CIGNA.
If the request is approved, your physician will receive confirmation and the authorization will be processed in the
CIGNA claims system. The length of authorization will depend on the diagnosis and prescription drug or supply.
If the request is denied, your physician and you will be notified. If you disagree with a coverage decision, you may
submit an appeal in writing following the guidelines outlined in the appeal section of this document.
If you have questions, you may call member services at the telephone number on your member ID card.
Formulary Rebate
Deluxe may receive a formulary rebate for certain pharmaceutical products.
Covered Expenses under the Prescription Drug Program
If you are enrolled in the Choice Fund (HRA), the following types of expenses are covered under both the retail
pharmacy and mail order programs:
•
Compound prescriptions
•
Oral contraceptives
•
Glucose testing strips or agents
•
Insulin
•
Insulin syringes
•
State-controlled substances
•
Prenatal vitamins
To find out which prescriptions are covered under the Choice Fund (HRA), you can contact CIGNA Tel-Drug at 1800-285-4812.
Non-covered Expenses under the Prescription Drug Program
Examples of expenses not covered under the prescription drug program include:
•
Allergy serum or syringes
•
Anorexiants (unless covered with prior authorization for medical necessity)
•
Blood and blood products
•
Cosmetic agents
•
Experimental drugs
•
Fertility drugs (oral)
•
Growth hormones (prior authorization for certain medical conditions)
•
Immunizations
•
Medical devices (ostomy supplies)
•
Nutritional supplements
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•
Over-the-counter products
•
Therapeutic devices (including needles and syringes)
SUMMARY PLAN
DESCRIPTION
Behavioral Health Care Benefits
Behavioral health care benefits are available to you through CIGNA Behavioral Health. Your benefits include
coverage for:
•
Mental health;
•
Alcoholism; and
•
Chemical dependency or drug addiction.
How Behavioral Health Care Benefits Work
Professional counselors are available to coordinate services for all types of behavioral health care, including
professional assessment, assistance, counseling, referrals, and arrangements for further treatment of behavioral
health issues, as well as alcohol and drug dependency.
Other Medical Plan Services
Under the Choice Fund (HRA) plan, you have access to additional services that can help you and your covered
dependents benefit fully from your medical coverage. You can access these services simply by calling the toll-free
number 1-800-CIGNA-24 (1-800-244-6224) shown on the back of your ID card or you can call 1-877-U-ASK-DLX
(1-877-827-5359) and select the Health and Insurance menu option. These additional services are described in the
following sections.
CIGNA’s Toll-Free Care Line
CIGNA’s toll-free care line is a medical advisory service provided through a health care professional. You may
access the health care professional by calling 1-800-CIGNA-24 (1-800-244-6224). You can call Monday through
Friday during normal business hours and talk to a registered graduate nurse (R.N.). The nurse can answer general
benefits questions regarding:
•
Preadmission certification; and
•
Locating physicians, hospitals, and other health care services, either in your area or in other cities, if you
require medical care while away from home.
CIGNA’s toll-free care line nurse cannot:
•
Answer specific questions about your medical coverage or claims;
•
Provide medical opinions or comment on the competency or reputation of a provider;
•
Prescribe medication; and
•
Give diagnoses or advice about treatments.
You may be referred to an appropriate resource for questions related to these topics.
Case Management
Case management services help you with short-term and catastrophic medical conditions by offering appropriate
treatment options that meet your needs and keep costs manageable.
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The goal of case management is to ensure that you receive appropriate care in the most effective setting possible,
whether at home as an outpatient, or as an inpatient in a hospital or specialized facility.
If you need case management, a case management professional will work closely with you, your family, and the
attending physician to determine appropriate treatment options.
The case manager helps coordinate the treatment program and arranges for necessary resources. Case managers
are also available to answer questions and provide ongoing support for your family during a medical crisis. Case
management includes registered graduate nurses and other credentialed health care professionals, each trained in
a clinical specialty area such as trauma, high-risk pregnancy, oncology, or mental health.
A case manager trained in the appropriate clinical specialty area will be assigned to you or your dependent. In
addition, case managers are supported by a panel of physician advisors who offer guidance on up-to-date
treatment programs and medical technology. While the case manager recommends alternate treatment programs
and helps coordinate needed resources, your attending physician remains responsible for the actual medical care.
How to Request Case Management Services
Here are the steps to follow to request case management services:
•
You, your dependent, or an attending physician can call the toll-free care line number shown on the back of
your health plan ID card: 1-800-CIGNA-24 (1-800-244-6224). Case managers are available Monday
through Friday, during normal business hours.
•
A health care professional will assess your case to determine whether case management is appropriate.
•
If case management is necessary, a case manager will contact you and explain how the program works.
Participation in the program is voluntary. There is no penalty or benefit reduction if you do not participate in
case management.
•
Your case manager will work with you, your family, and the physician to determine the needs of the patient
and to identify what alternate treatment programs are available — for example, in-home medical care
instead of an extended inpatient hospital stay. You are not penalized if you do not follow the alternate
treatment program.
•
Your case manager arranges for alternate treatment services and supplies, as needed — for example, if
you need a hospital bed for your home.
•
Your case manager also acts as a liaison between you, your family, the insurance company, and the
physician, as needed.
•
Once the alternate treatment program is in place, your case manager continues to manage your case to
ensure the treatment program remains appropriate for your needs.
Although participation in case management is voluntary, case management professionals can offer quality, costeffective treatment alternatives, as well as obtain needed medical resources and ongoing family support in a time of
need.
CIGNA LIFESOURCE Organ Transplant Network
CIGNA offers you access to innovative and technologically advanced options for organ transplants. As a CIGNA
participant, you will be able to access the CIGNA LIFESOURCE Organ Transplant Network, an organization of
participating hospitals that provide outstanding organ transplant services. Developed by a team of highly respected
medical professionals, the network includes leading hospitals and medical centers throughout the United States.
If you need transplant services, call 1-800-CIGNA-24 (1-800-244-6224). Registered graduate nurses are available
to assist you.
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Medical Plan Claim Information
If you are covered under the Choice Fund (HRA) plan and receive care outside the network, you pay for medical
charges at the time you receive treatment. To get reimbursed for these charges, you must file your own claim with
CIGNA.
How to File a Medical Plan Claim
Generally, the sooner you file your claim, the sooner you receive payment. It is not necessary for you to complete a
claim form when submitting claims for reimbursement. Just follow the steps below. If claims are not submitted
within 180 days after the date of service, the claims will not be considered valid and will be denied.
Send itemized bills (i.e., doctor, hospital, lab) directly to the CIGNA claims office address listed on the back of your
member ID card. Include your member ID number and the Deluxe account number which is 3173992.
If you want to use a claim form, you can access it through CIGNA's Web site at www.cigna.com or call the CIGNA
Customer Care Center at 1-800-CIGNA-24 (1-800-244-6224).
CIGNA is the claims administrator for the CIGNA Choice Fund HRA plan. As the claims administrator, CIGNA is
responsible for reviewing and processing claims.
CIGNA is the authorized claims administrator for:
•
Initial benefit determinations
•
First level appeals,
•
Second level appeals, and
•
All appeals involving urgent care.
Claim Reminders
• Be sure to use your member ID number and the Deluxe account number when you submit claims for
reimbursement, or when you call your CIGNA claims office. The Deluxe account number is 3173992.
•
If you knowingly present a false or fraudulent claim for payment of a loss or benefit, you are guilty of a
crime and may be subject to termination, fines and confinement in prison.
Payment of Benefits
When medical services are provided by a CIGNA network provider, all health plan benefits are paid directly to the
provider. If services are provided by a non-network provider, benefits are payable to you, however, at the option of
the provider and with your consent, all or part of the benefits may be paid directly to the person or institution that
provided the services.
If benefits are payable to a minor, the payment is made to his or her legal guardian. If the legal guardian has not
requested payment, the payment may be made to the provider instead.
If you die while any benefits remain unpaid, direct payment is made to one of these individuals:
•
Your spouse/domestic partner;
•
Your child(ren);
•
Your mother or father;
•
Your siblings; or
•
The executors or administrators of your estate.
NOTE: If you or your dependent are confined in an inpatient setting at the time of the effective date of the Choice
Fund (HRA), your previous carrier will continue to be responsible for the stay until you are discharged or have a
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change in the level of care. All claims must be submitted to your previous carrier. CIGNA will administer any
subsequent medical services after the confinement.
When You Will Receive Payment
Benefits are paid after you have provided CIGNA with all the information necessary for processing the claim.
Post-Service Claims
Post-service claims are claims for benefits that are filed after medical care has been received. If your post-service
claim is denied, you will receive a written notice from CIGNA within 30 days after the claim was received, as long as
all needed information was provided with the claim.
Additional time may be necessary to process a claim due to circumstances beyond the control of the Plan. If an
extension is necessary, CIGNA will notify you in writing within the 30-day period of the reasons for the extension
and the date by which it expects to make a decision. The extension generally will be no longer than 15 days, unless
additional information is needed.
If the extension is necessary because you failed to provide all needed information, the notice of the extension will
describe the additional information required. You will have 45 days to provide the additional information. If all the
additional information is received within 45 days, CIGNA will notify you of its claim decision within 15 days after the
information is received. If you do not provide the needed information within the 45-day period, CIGNA will deny the
claim.
Pre-Service Claims
Pre-service claims are claims that require notification or approval before you receive medical care (for example,
inpatient care or transplant procedures). If your pre-service claim is submitted properly with all needed information,
CIGNA will send you a notice of the benefit determination, whether adverse or not, no later than 15 days after the
claim is received.
If an extension is necessary to process your pre-service claim because of circumstances beyond the control of the
Plan, CIGNA will notify you in writing within the initial 15-day response period of the reasons for the extension and
the date by which it expects to make a decision. The extension generally will be no longer than 15 days, unless
additional information is needed. If the extension is necessary because you failed to provide all needed information,
the notice of the extension will describe the additional information required. You will then have 45 days to provide
the additional information. If all the needed information is received within 45 days, the claims administrator will
notify you of the determination within 15 days after the information is received. If you do not provide the needed
information within the 45-day period, the claims administrator will deny the claim.
Urgent Care Claims
Urgent care claims are claims that require notification or approval before care is received — and if a delay in the
care:
•
could seriously jeopardize your life or health or your ability to regain maximum function, or
•
in the opinion of a physician with knowledge of your medical condition, could cause severe pain.
If you follow the Plan’s procedures when filing an urgent care claim and include all needed information, CIGNA will
notify you of the determination, whether adverse or not, as soon as possible, but not later than 72 hours after
receipt of the urgent claim.
However, if you fail to follow the Plan’s procedures, CIGNA will notify you of the improper filing and how to correct it
within 24 hours of receipt of the improper claim. This notification may be oral, unless you request a written
notification.
If you fail to provide the information that is needed to decide your urgent claim, CIGNA will notify you of the required
or additional information within 24 hours after the claim is received. You will then have 48 hours to provide the
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requested information. You will be notified of the determination on your claim no more than 48 hours after the
earlier of:
•
CIGNA’s receipt of the requested information, or
•
the end of the 48 hours given to you to provide the requested information.
A denial of an urgent care claim will include the information listed above for post-service claim denials, and also a
description of the expedited review process for such claims. Notifications regarding urgent care claim
determinations will be done expeditiously by phone, fax or other methods, and may be oral, in which case written or
electronic (via email) confirmation will follow within three days.
Concurrent Care Claims
There are two types of concurrent care claims:
•
a claim to extend coverage for a course of treatment beyond a previously approved period of time or
number of treatments, or
•
a claim regarding reduction or termination of coverage by the Plan before the end of a previously approved
period of time or number of treatments.
You must submit a request to extend an ongoing course of treatment at least 24 hours before the end of the
previously approved limit. If your request for extension is made in a timely manner and involves urgent care, CIGNA
will notify you of the determination, whether adverse or not, within 24 hours after the claim is received. If your claim
is not made at least 24 hours before the end of the previously approved limit, the request will be treated as an
urgent care claim (not a concurrent care claim) and decided according to specified timeframes (see Urgent Care
Claims).
A request to extend coverage that does not involve urgent care will be considered a new claim and will be decided
according to the post-service or pre-service timeframes described previously, whichever applies.
Questions about Benefit Determinations
If you have questions or concerns about a benefit determination, you may informally contact CIGNA customer
service before requesting a formal appeal. If the customer service representative cannot resolve the issue to your
satisfaction over the phone, you may submit your questions in writing. Remember, however, that if you are not
satisfied with a benefit determination, you may appeal it immediately as described in the section that follows,
without first informally contacting customer service.
When You Have a Complaint or an Appeal
For the purposes of this section, any reference to "you" or "your" also refers to a representative or provider
designated by you to act on your behalf; unless otherwise noted.
We want you to be completely satisfied with the care you receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start With Customer Service
We are here to listen and help. If you have a concern regarding a person, a service, the quality of care,
contractual benefits, or a rescission of coverage, you may call the toll-free number on your ID card, explanation
of benefits, or claim form and explain your concern to one of our Customer Service representatives. You may
also express that concern in writing.
We will do our best to resolve the matter on your initial contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in any case within 30 days. If you are not satisfied with
the results of a coverage decision, you may start the appeals procedure.
Internal Appeals Procedure
To initiate an appeal, you must submit a request for an appeal in writing to Cigna within 180 days of receipt of a
denial notice. You should state the reason why you feel your appeal should be approved and include any
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information supporting your appeal. If you are unable or choose not to write, you may ask Cigna to register your
appeal by telephone. Call or write us at the toll-free number on your ID card, explanation of benefits, or claim form.
Your appeal will be reviewed and the decision made by someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will be considered by a health care professional.
We will respond in writing with a decision within 30 calendar days after we receive an appeal for a required
preservice or concurrent care coverage determination or a postservice Medical Necessity determination. We will
respond within 60 calendar days after we receive an appeal for any other postservice coverage determination. If
more time or information is needed to make the determination, we will notify you in writing to request an extension
of up to 15 calendar days and to specify any additional information needed to complete the review.
In the event any new or additional information (evidence) is considered, relied upon or generated by Cigna in
connection with the appeal, Cigna will provide this information to you as soon as possible and sufficiently in
advance of the decision, so that you will have an opportunity to respond. Also, if any new or additional rationale is
considered by Cigna, Cigna will provide the rationale to you as soon as possible and sufficiently in advance of the
decision so that you will have an opportunity to respond.
You may request that the appeal process be expedited if, (a) the time frames under this process would seriously
jeopardize your life, health or ability to regain maximum functionality or in the opinion of your Physician would
cause you severe pain which cannot be managed without the requested services; or (b) your appeal involves
nonauthorization of an admission or continuing inpatient Hospital stay.
If you request that your appeal be expedited based on (a) above, you may also ask for an expedited external
review at the same time, if the time to complete an expedited review would be detrimental to your medical
condition.
When an appeal is expedited, Cigna will respond orally with a decision within 72 hours, followed up in writing.
External Review Procedure
If you are not fully satisfied with the decision of Cigna's internal appeal review and the appeal involves medical
judgment or a rescission of coverage, you may request that your appeal be referred to an Independent Review
Organization (IRO). The IRO is composed of persons who are not employed by Cigna, or any of its affiliates. A
decision to request an external review to an IRO will not affect the claimant's rights to any other benefits under the
plan.
There is no charge for you to initiate an external review. Cigna and your benefit plan will abide by the decision of
the IRO.
To request a review, you must notify the Appeals Coordinator within 4 months of your receipt of Cigna's appeal
review denial. Cigna will then forward the file to a randomly selected IRO. The IRO will render an opinion within 45
days.
When requested, and if a delay would be detrimental to your medical condition, as determined by Cigna's Physician
reviewer, or if your appeal concerns an admission, availability of care, continued stay, or health care item or service
for which you received emergency services, but you have not yet been discharged from a facility, the external
review shall be completed within 72 hours.
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in writing or electronically and, if an adverse
determination, will include: information sufficient to identify the claim; the specific reason or reasons for the adverse
determination; reference to the specific plan provisions on which the determination is based; a statement that the
claimant is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents,
records, and other Relevant Information as defined below; a statement describing any voluntary appeal procedures
offered by the plan and the claimant's right to bring an action under ERISA section 502(a), if applicable; upon
request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied
upon in making the adverse determination regarding your appeal, and an explanation of the scientific or clinical
judgment for a determination that is based on a Medical Necessity, experimental treatment or other similar
exclusion or limit; and information about any office of health insurance consumer assistance or ombudsman
available to assist you in the appeal process. A final notice of an adverse determination will include a discussion of
the decision.
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You also have the right to bring a civil action under Section 502(a) of ERISA if you are not satisfied with the
decision on review. You or your plan may have other voluntary alternative dispute resolution options such as
Mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and
your State insurance regulatory agency. You may also contact the Plan Administrator.
Relevant Information
Relevant information is any document, record or other information which: was relied upon in making the benefit
determination; was submitted, considered or generated in the course of making the benefit determination, without
regard to whether such document, record, or other information was relied upon in making the benefit determination;
demonstrates compliance with the administrative processes and safeguards required by federal law in making the
benefit determination; or constitutes a statement of policy or guidance with respect to the plan concerning the
denied treatment option or benefit for the claimant's diagnosis, without regard to whether such advice or statement
was relied upon in making the benefit determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring a civil action under section 502(a) of ERISA if you are
not satisfied with the outcome of the Appeals Procedure. In most instances, you may not initiate a legal action
against Cigna until you have completed the appeal processes.
Recovery of Overpayment
If you or a medical provider is paid more benefits than you are eligible to receive under your medical plan, CIGNA
has the right, at any time, to:
•
Recover that overpayment from you or the person to whom it was made on your behalf; or
•
Offset the amount of overpayment from a future claim payment.
What Happens to Your Medical Plan Benefits When You Leave the Company?
If you leave the company below is important information you should know about your medical plan benefits.
When Medical Plan Coverage Ends
Deluxe medical plan coverage for you and/or your dependents ends on the earliest of the following:
•
The date you cease to be in a class of eligible employees or no longer qualify for coverage;
•
The last day for which you have made any required contribution for coverage;
•
The date the medical plan policy is canceled; or
•
The last day of your employment with a participating Deluxe related company.
Deluxe reserves the right to amend or terminate any of its plans at any time without notice to, or consent of,
employees, retirees, or their dependents.
When your coverage under a Deluxe health plan ends, you will receive a certificate of group health plan coverage.
You may take this certificate to another health care plan to receive credit for your coverage with the company. You
will only need to do this if the other health care plan has a pre-existing condition limit. Coverage under the Plan will
not be considered by another plan if the coverage is followed by a break in coverage of 63 days or more.
How to Continue Medical Plan Coverage
You and your dependents may be eligible to continue some coverage under COBRA and convert other healthrelated coverage to individual policies.
Guidelines Affecting Your Medical Plan Benefits
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Here are some guidelines that are important to know regarding your medical plan benefits.
Coordination of Benefits (COB)
When an individual is covered by two group medical plans, benefits from each are coordinated so that you or your
dependents do not receive benefits that are greater than the actual covered medical expenses. One plan (the
primary plan) pays benefits first, while the other (the secondary plan) pays second. The secondary plan considers
what the primary plan paid before paying benefits.
Insurance companies and plan administrators use an "order of benefit determination" to answer the question of
which plan is primary. The rules below establish the order in which benefits are paid:
•
The plan covering the patient as an employee or nondependent pays benefits first.
•
If the patient is a dependent child of non-divorced or non-separated parents, the plan of the parent whose
birthday is earlier in the calendar year pays first. If the birthdays of both parents are the same, the plan
covering the patient for the longest time pays benefits first. If the other plan does not have a COB birthday
rule, that plan's COB rule determines the order of benefits.
•
If the patient is a dependent child of divorced or separated parents, the plan of the parent ordered by court
decree to provide health care coverage pays first. If there is no court decree ordering health care coverage
and the custodial parent has not remarried, that parent's plan pays first. If the custodial parent has
remarried, the custodial parent's plan pays first, the stepparent's plan pays second, and the noncustodial
parent's plan pays third.
Coordination with Medicare
You become eligible for Medicare by either reaching age 65 or becoming disabled. If you (or your spouse) are over
age 65 and you are an active employee, you may choose Medicare or the Deluxe employee medical plan as your
primary coverage. You will have the opportunity to choose your primary coverage once a year. If you have the
Deluxe plan as primary coverage, you may feel you do not need Medicare as a supplement as long as you are an
active employee. You may then enroll in Medicare when you retire. Whether you are an active or a retired
employee, you should enroll in Medicare Part A and B if you or an eligible dependent is diagnosed with chronic
renal disease.
Under federal law, the Medicare Secondary Payer Rules do not apply to domestic partners covered under a group
health plan. Therefore, Medicare is always the primary plan for a person covered as a domestic partner, and the
Deluxe plan is secondary.
When Medicare is determined to be your primary payer, the benefits provided by the Deluxe employee medical
plan are reduced by an amount equal to the benefits you are entitled to receive under Medicare. Please note that
as a qualified retiree, eligible for medical coverage through Deluxe, when you qualify for Medicare, Medicare
becomes your primary coverage. It pays first, and the Deluxe plan then considers the charges Medicare did not
cover. The Deluxe plan pays the difference between what Medicare pays and what the Deluxe plan would have
paid alone. This reduction in benefits will occur whether or not you actually enroll in Medicare A and B or pay the
required Medicare premium.
It is very important for you to enroll in Medicare coverage, both Parts A and B, when you retire and become eligible
so that you have adequate medical coverage. This also applies to former Deluxe employees who become eligible
for Medicare due to disability (after two years of disability). However, it is important that you do not enroll in an
independent Medicare Part D plan for prescription drug coverage. You cannot participate in an independent
Medicare Part D plan and this medical plan at the same time. The prescription drug coverage in this plan is
creditable coverage and has been certified to be on average as good as the standard Medicare prescription drug
coverage. If you enroll in an independent Medicare Part D prescription drug plan, your medical coverage in this
plan will be terminated.
Your Benefits Resources (YBR) will mail a certificate of creditable coverage to post 65 participants each year. If you
would like a copy during the year, call Your Benefits Resources (YBR) at 1-877-U-ASK-DLX or 1-877-827-5359 to
request one.
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MEDICAL – CHOICE FUND HRA
SUMMARY PLAN
DESCRIPTION
Right of Reimbursement
The Deluxe medical plans do not cover:
•
Expenses for which another party may be responsible as a result of liability for causing or contributing to
the injury or illness of you or your dependents; or
•
Expenses to the extent they are covered under the terms of any automobile medical, automobile no-fault,
uninsured or underinsured motorist, Workers' Compensation, or government insurance (other than
Medicaid or similar type of insurance).
If you or a dependent incurs medical expenses as a result of either of the above, CIGNA automatically places a lien
upon the proceeds of any payment made to you or your dependents, or to your estate in the event of your death.
Subrogation
If you receive benefits for a sickness or injury caused by another person or organization and are reimbursed for
those medical expenses by the party at fault, you must pay back whatever benefit the Plan may have paid on your
behalf.
This policy, called subrogation, prevents duplicate payments. Examples include amounts you receive through
lawsuits and settlements or from any third party or insurer. You and your dependents have a legal obligation to help
the Plan in all possible ways in cases of subrogation. The claims administrator and the Plan administrator may take
any action necessary under this provision on behalf of the Plan.
The Plan also has the right to receive and release necessary information to determine whether subrogation or any
similar provisions apply to a claim. By participating in the Open Access Plus, you agree to furnish any information
that the claims administrator or the Plan administrator requires in order to enforce these provisions.
Reimbursement of Common Accident Expenses
If you and one of your covered dependents, or two or more of your covered dependents, are injured in the same
accident and incur covered expenses for those injuries in the calendar year in which the accident occurs, not more
than one deductible is applied to the total covered expenses incurred for them during the rest of that calendar year.
Use of Health Information
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that, in part, requires
group health plans to protect the privacy and security of your confidential health information. As an employee
welfare benefit plan under ERISA, the Plan is subject to the HIPAA privacy rules. This means that the Plan will not
use or disclose your protected health information without your authorization, except for purposes of treatment,
payment, health care operation, or Plan administration, or as required or permitted by law. A description of the
Plan's uses and disclosures of your protected health information and your rights and protections under the HIPAA
privacy rules is set forth in the Deluxe Corporation's Notice of Privacy Practices.
Leave of Absence
Under the Family and Medical Leave Act of 1993, you may have the right to take a leave of absence to care for
yourself or an ill family member, or after the birth or adoption of a child.
When you take an eligible family leave, by law, your health care benefits may be continued during your leave as
long as you pay the monthly premium as billed by the Your Benefits Resources center. Upon your return to active
service following a leave of absence that qualifies under the Family and Medical Leave Act of 1993, any canceled
insurance will be reinstated as of the date of your return.
For more information about the Family and Medical Leave Act, contact your local Human Resources Department.
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