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Home My WebLink AboutWellmark-5/4/2015 (5)OBS - OBS ID: 188067-17 Page 1 of 6 Note: This is a summary of benefits under this plan, not a statement of contract. The actual terms and conditions of coverage will be specified in the Group Insurance Policy issued by Wellmark or the Administrative Services Agreement between Wellmark and the entity below, as well as the Benefits Certificate and any amendments thereto. Benefit Summary - CITY OF WATERLOO Group Number/BU: XA025-0001 Group Product Summary ID: 188067-17 Coverage Code: Alpha Prefix: CWW Benefit Dates: 7/1/2015 - 6/30/2016 Summary Status: Rating Account Manager: Harford, DeVonne alt:500/1000 PPO ded; dental acc-12 mos Group Information Group Street Address 1: Mayors Office Group Street Address 2: 715 Mulberry Street City/State/ZIP: Waterloo , IA 50703 Product/Version: Alliance Select (201009) Account Signatur.�,�� Date /2-7 //l 5— General General Renewing group Self-funded arrangement Group is a govemment entity Union group Current union contract expiration date: 06/30/2016 Plan year begins on: 07/01 Healthcare Reform Non -Grandfathered Plan Benefit period is calendar year BlueCard PPO - In states with no PPO or PPO specialty, providers are treated as PPO as determined by Wellmark and the local Blue plan Eligibility An eligible child is married or unmarried and is under 26 years of age. An eligible child is an unmarried dependent full-time student regardless of age. An eligible child is disabled before age 26 and remains unmarried after age 26. An eligible child is unmarried and disabled while a full-time student after age 26. Dependent coverage terminates at the end of the month Two-way rate (single/family) Unmarried domestic partners are NOT covered http://wellnetapp.int.wellmark.com/secure/obs/smryansw. asp?BUBSID=10... 4/16/2015 OBS - OBS ID: 188067-17 Page 2 of 6 Certificate coverage ends at the end of the month Subrogation applies Standard administration of coordination of benefits (COB) Routine maternity benefits apply to employee and spouse only Do not include ERISA Information Requirements language Coordination of benefits rules apply to members when Medicare is the primary payer Additional eligibility information: Benefits for any person covered by Medicare Part A who does not purchase Medicare Part B are reduced by the benefit amount to which they are entitled, or could have been entitled with enrollment under Medicare Part B. Preexisting Condition Exclusion Periods New hires and special enrollees are covered when first eligible or at each group renewal. New hires and special enrollees are NOT subject to preexisting condition exclusion periods Late enrollees (a member who is not a new hire or special enrollee) may enroll at each group renewal. Late enrollees are NOT subject to preexisting condition exclusion periods Deductibles Coverage has benefit period deductibles Single deductible for PPO providers is: $ 500 Single deductible for non -PPO providers is: $ 1,000 Family deductible for PPO providers is: $ 1,000 Family deductible for non -PPO providers is: $ 2,000 Dual deductible amounts are aggregate (both ways) PPO and non -PPO deductibles apply to each other Member has benefits after single deductible met; entire family has benefits after family/two- person deductible met when deductible is applicable Deductible from the previous 4th quarter will NOT carry over to this year's benefit period deductible Common accident deductible does NOT apply No Wellmark-to-Wellmark deductible credit. Credits will not transfer from one Wellmark employer group to another Wellmark employer group. Physician services for well-child care is NOT subject to the deductible Physician services for newborn care is NOT subject to the deductible. Facility services for well-child care is NOT subject to the deductible. Facility services for newbom's initial hospitalization are NOT subject to the deductible PPO outpatient preventive care is NOT subject to the deductible PPO office services and PPO independent lab fees are NOT subject to the deductible http ://wellnetapp . int.wellmark. com/s ecure/obs/smryansw. asp?BUB SID=10... 4/16/2015 OBS - OBS ID: 188067-17 Page 3 of 6 Most outpatient x-ray/lab services from PPO facilities are subject to the deductible One postpartum home visit if released within 48 hours after a vaginal delivery/96 hours after a cesarean delivery is NOT subject to the deductible All services with copays are NOT subject to the deductible Preventive care from PPO providers is NOT subject to the deductible Prosthetic limbs from PPO providers are NOT subject to the deductible Other services NOT subject to the deductible are: -PPO office visit and independent labs for MHCD services -Preventive care from participating providers Additional deductible information: Therapy Benefits: Occupational, Speech and Physical (excluding Chiro) Therapies apply deductible. Copay Primary Care Practitioner (PCP) is defined as General Practice (01), Family Practice (08), Internal Medicine (11), Obstetrics/gynecology (16), Pediatricians (37), and Nurse Practitioners (50 and 89), Physician Assistants (97). Office PCP copay - includes MHCD unless stated otherwise is: $ 20 Office Chiropractor copay amount is the same as the office PCP copay amount listed above All other providers are Non -Primary Care Practitioners (Non -PCP). Office non -PCP copay - includes MHCD unless stated otherwise is: $ 40 Office visit copay applies to services received from PPO practitioners Office visit copay is taken once per practitioner per date of service Office visit copay applies to any office services Preventive care is NOT subject to the office visit copay (copay is waived for preventive care) Services NOT subject to office visit copay are: -Therapy Benefits: Occupational, Speech and Physical (excluding Chiro) Therapies - deductible and coinsurance will apply. Office visit copay applies to the out-of-pocket maximum. Copay does NOT continue after the out-of-pocket maximum is met Deductible does NOT follow office visit copay Coinsurance does NOT follow office visit copay The following services have a different office visit copay: $20 copay for MHCD services. $20 copay for Acupuncture. Coinsurance Coinsurance for PPO providers is the following percentage: 20 Coinsurance for non -PPO providers is the following percentage: 40 http://wellnetapp. int.wellmark. com/s ecure/obs/smryansw. asp?BUB SID=10... 4/16/2015 OBS OBS ID: 188067-17 Page4of6 One postpartum home visit if released within 48 hours after vaginal delivery/96 hours after cesarean delivery is NOT subject to coinsurance Services subject to copay are NOT subject to coinsurance Preventive care from PPO providers is NOT subject to coinsurance Other services NOT subject to coinsurance are: -PPO office visit and independent labs for MHCD services. -Preventive care from PAR providers Additional coinsurance information: Therapy Benefits: Occupational, Speech and Physical (excluding Chiro) Therapy apply coinsurance. Out of Pocket Maximum Out-of-pocket maximums apply Single out-of-pocket maximum for PPO providers is: $ 1,000 Single out-of-pocket maximum for non -PPO providers is: $ 2,000 Family out-of-pocket maximum for PPO providers is: $ 2,000 Family out-of-pocket maximum for non -PPO providers is: $ 4,000 Dual out-of-pocket maximum amounts are aggregate (both ways) - PPO and non -PPO out- of-pocket maximum amounts apply to each other Deductible amounts apply to the out-of-pocket maximum Coinsurance for all services apply to the out-of-pocket maximum Deductible from the previous 4th quarter will NOT carry over to the out-of-pocket maximum for this year Coinsurance from the previous 4th quarter will NOT carry over to the out-of-pocket maximum for this year No Wellmark-to-Wellmark out-of-pocket credit. Credits will not transfer from one Wellmark employer group to another Wellmark employer group Additional out-of-pocket maximum information: Participating providers subject to the PPO OPM Lifetime Maximum Lifetime maximum is unlimited Lifetime maximum for hospice respite is limited to 15 days inpatient/15 days outpatient Facility Services Iowa Psychiatric Medical Institutions for Children are covered according to state mandate The cost of blood, blood components, and derivatives are covered Nonparticipating facility claims are based on maximum allowable fee You are covered for nursing services received in a hospital or nursing facility with no limit. Services must be ordered and certified by your attending physician. Practitioner Services http://wellnetapp. int.wellmark.com/secure/obs/smryansw.asp?BUB SID=10... 4/16/2015 OBS - OBS ID: 188067-17 Page 5 of 6 Advanced nurse practitioners are covered Physician assistants are covered Licensed marriage family therapists are covered. Licensed mental health counselors are covered. Dental treatment for accidental injury is covered if completed within 12 months Surgical removal of impacted teeth is covered as an inpatient with a concurrent medical condition. Outpatient services are covered without a concurrent medical condition Treatment of temporomandibular joint disorder is covered, except for dental restorations/extractions, and orthodontic treatment Chiropractor services are covered as medically necessary Preventive Care/Immunizations/Mammography Preventive physical exams are covered. A separate gynecological exam is also covered One preventive physical exam per member per benefit period is covered Women's preventive care services are covered according to the ACA mandate Immunizations are covered (Travel Immunization excluded) Mammography benefits are covered according to Iowa mandate for women. Age 35-39 = one base mammogram, age 40-49 = one mammogram every two years, 50 years of age and older = one mammogram every year. Preventive Pap smears are unlimited Routine vision exams are NOT covered Well-child and newborn care is covered according to mandate Hearing aids are covered as follows: Limited to $600 every 36 months. Routine hearing exams are covered as follows: Limited to $600 every 36 months combined with hearing aid benefit. Prescription Drugs/Contraceptives Retail drugs are covered under a Prescription Drug Program Prescription drugs/items for smoking cessation are covered under a Rx Program; related exams are covered under health Smoking cessation consultations are included as part of preventive care Contraceptives are covered. Oral and drug delivery devices, such as insertable rings and patches, are covered under a Rx Program; injected, implanted, and medical devices, such as intrauterine devices and diaphragms, are covered under health Contraceptives covered under health are included as part of preventive care Most specialty self-administered drugs are covered under the Prescription Drug Program, NOT under Health. This drug listing can be found on www.wellmark.com under the General Pharmacy Information Other Services Supplemental accidental injury benefits are NOT covered http ://wellnetapp. int.wellmark. com/s ecure/obs/smryansw. asp?BUB SID=10... 4/16/2015 OBS - OBS ID: 188067-17 Page 6 of 6 Reminder Programs is not available Diabetic education programs are covered according to mandate Hospice services are covered Infertility benefits are NOT covered Coverage for Home Medical Equipment is unlimited. Bariatric surgery and related treatment is covered Major organ transplants are covered. Prior approval required. Transplants are NOT limited to Blue Distinction Centers for Transplant MHCD Mental health/chemical dependency treatment is unlimited Notification Requirements If you are admitted to a nursing facility, an acute rehabilitation facility, or a hospital outside the states of Iowa or South Dakota, you or someone acting on your behalf must contact us to precertify your admission. Refer to www.wellmark.com for other services subject to precertification. Related facility services may be subject to a reduction for failure to follow notification requirements - refer to your coverage manual or plan description for details. All services are subject to reduction for failure to follow notification requirements. Iowa Psychiatric Medical Institutions for Children is subject to precertification. Failure to precertify will result in a benefit reduction. All services are subject to reduction for failure to follow notification requirements Reduction for failure to precertify is 50 percent Additional Information Exclude elective abortion. Acupuncture is covered. SPD Requested. http://wellnetapp.int.wellmark.com/secure/obs/smryansw.asp?BUB SID=10... 4/16/2015