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«2016 Effective Plan Year UPMC Vision Care Certificate of Insurance PPO Vision Plan Welcome and General Information for Members This document is your ...»

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2016

Effective Plan Year

UPMC Vision Care

Certificate of Insurance

PPO Vision Plan

Welcome and General Information for Members

This document is your Certificate of Insurance (“Certificate”). Your Certificate establishes the terms of coverage for your

vision plan. It sets forth which services are covered and which services are not covered. It explains the procedures that

you must follow to ensure that the vision services you receive will be covered under your benefit plan. It also describes how you can add a dependent to your plan, submit a claim, file a Complaint, and other information that you may need to know to access your vision benefits. The Certificate acts as a contract between you and the Plan*, setting forth your obligations as a Member and our obligations as your vision administrator. It is important to use this Certificate along with your Schedule of Benefits. Your Schedule of Benefits is the document that outlines your coverage amount and Benefit Limits.

This preferred provider organization benefit plan may not cover all of your vision expenses. Read this contract carefully to determine which vision services are covered.

Health Care Concierge team To help you get accurate answers to questions and up-to-date information about your vision program, please visit MyHealth OnLine via www.upmchealthplan.com, call 1−844-252-0687, or write to UPMC Vision Care,

U.S. Steel Tower, 600 Grant Street, Pittsburgh, PA 15219. You can:

• Learn about UPMC Vision Care

• Find network vision providers

• Verify eligibility for yourself and your dependents

• Request a Non-Participating Vision Provider reimbursement form

• Speak with our Health Care Concierge team via phone or online chat

• Ask any questions about your vision care benefits

• Initiate a Complaint of a benefit denial Our Health Care Concierge team is available Monday through Friday from 7 a.m. to 7 p.m. and Saturday from 8 a.m. to 3 p.m. at 1−844-252-0687. Members who use a TTY (teletypewriter) may access TTY services by calling 1-800-361-2629.

Helpful phone numbers

• Member Health Care Concierge- 1-844-252-0687

• Provider Line- 1-877-262-7870

• TTY Services- 1-800-361-2629

• Provider Fraud and Abuse- 1-866-FRAUD01

• UPMC Fax- 1-888-830-5560 *UPMC Vision Care is a product of UPMC Health Benefits Inc. and administered by National Vision Administrators (NVA). References to the Health Plan or the Plan shall refer to UPMC Health Plan, Inc. and UPMC Health Benefits, Inc.

–  –  –

Terms and Definitions to Help You Understand Your Coverage

Eligibility and Enrollment – When Coverage Begins

How the Vision Plan Works

Benefits

Claims

Resolving Disputes with the Plan

Termination – When Coverage Ends

Schedule of Exclusions

General Provisions

–  –  –

The following are some important, frequently used terms and definitions that the Plan uses in this Certificate and when administering your benefits.

Benefit Limit – The maximum amount that the Plan will pay for a Covered Service. Some Benefit Limits are discussed in this Certificate, but generally Benefit Limits are set forth in your Schedule of Benefits.

Benefit Period – The period (for which you are eligible for coverage during your employer group/plan sponsor’s contract year) during which charges for Covered Services must be incurred in order to be eligible for payment by the Plan. A charge is considered incurred on the date you receive the service or supply.

Complaint – A dispute or objection by a Member regarding a Participating Vision Provider or the coverage (including contract exclusions and non-covered benefits), operations, or management policies of this vision plan, which has been filed with the Plan but has not been resolved by the Plan. Instructions on how to file a Complaint are set forth in the Resolving Disputes with the Plan section of this Certificate.

–  –  –

Copayment – The specified dollar amount that you pay at the time of service for certain Covered Benefits. You are expected to pay your Copayment at the time of service. Refer to your Schedule of Benefits to determine Copayment amounts.

–  –  –

Daily Wear Contact Lenses – Contact Lenses that are approved and intended for wear during a single awake period of time, not to exceed the number of hours recommended by an eye care professional. Each day they are to be removed from the eye, cleaned and sterilized. They are not intended for or approved for sleep.

Experimental/Investigational – Any treatment, procedure, equipment, drug, device, or supply which is not accepted standard vision practice by the general vision community or does not have federal or government agency approval.

Extended Wear (Planned Replacement/Frequent Replacement) Contact Lenses – Contact lenses that may be utilized for a specified period of time, i.e. daily, 1 week, 2 weeks, etc. at which time they are discarded. In most cases they are removed, cleaned and sterilized following wear. In some cases they may be worn while sleeping, if approved by an eye care professional. Wearing schedules and duration of use must be as prescribed.





Maximum Allowable Fee Schedule Amount – The maximum amount the Plan will allow for a Covered Service.

Member – An individual or dependent who is enrolled in and covered by this Certificate.

National Vision Administrators (NVA)® – A third party vision administrator that provides benefit programs and a provider network for UPMC Vision Care Members.

–  –  –

Participating Vision Provider – A vision provider who has entered into an agreement with the Plan to render Covered Services to UPMC Vision Care Members through an arrangement with National Vision Administrators.

Proof of Loss – Documentation to support a claim.

Rider – A document that modifies your Certificate. A Rider may expand or restrict the benefits set forth in your Certificate. If you are unsure if you have a Rider, contact UPMC Vision Care or your employer or plan sponsor.

Schedule of Benefits – List of Covered Services, Copayments, and Benefit Limits.

Service Area – The Plan’s primary Service Area which consists of the counties listed in the most current version of the UPMC Vision Care provider directory. These are the counties in which UPMC Vision Care is licensed to do business and in which most of its Participating Vision Providers are located.

Specialty Contact Lenses – Lenses that require additional professional time in fitting and follow up care. These include Rigid Gas (O2) Permeable lenses, Toric (correct for astigmatism) lenses and Multi-focal lenses.

–  –  –

Who is eligible for coverage?

You are eligible for coverage if you are an employee of the covered employer/plan sponsor and you meet any additional eligibility criteria established by your employer and/or the Plan. Other than yourself, you may enroll the following

individuals as dependents:

• Your spouse under a legally valid existing marriage. A spouse does not include an individual who is eligible for Medicare coverage because of his or her age and who has elected that coverage instead of coverage offered under this Certificate.

• Children under 26 years of age, including newborn children, stepchildren, children legally placed for adoption, and children for whom coverage is mandated by a Qualified Medical Child Support Order are eligible for coverage under the terms of this Certificate, except as provided in an Eligibility Rider.

o For Affordable Care Act (ACA) compliant plans, children under the age of 19 may be covered for pediatric vision Essential Health Benefits (EHB) under their medical policy. For more information, please refer to your medical plan documents.

• Disabled dependents who meet the criteria set forth in the section titled “Disabled Dependents”, located in the “How do you enroll a dependent?” section.

To obtain coverage for a dependent, you may be required by your employer, plan sponsor, and/or the Plan to provide proof that the individual meets criteria for one of the above eligibility categories.

How do you enroll a dependent?

There are two ways you can enroll an eligible dependent. First, you may enroll an eligible dependent during your open enrollment period. Second, you may enroll an eligible dependent within 31 days of the date on which the dependent becomes eligible for coverage. You must complete and submit an enrollment application to your employer or plan sponsor within the 31-day period. The following are rules for special circumstances regarding coverage of dependents.

Newborn children: Newborn children are covered automatically from the moment of birth for 31 days. To obtain coverage for that child beyond the initial 31-day period, you must contact your employer or plan sponsor to enroll the child as a dependent before the end of the initial 31-day coverage period. If you do not contact your employer or plan sponsor, coverage for that child will end after the 31-day automatic coverage period.

Adopted children: Adopted children are covered automatically from the date of legal placement for 31 days. To obtain coverage for that child beyond the initial 31-day period, you must contact your employer or plan sponsor to enroll the child as a dependent before the end of the 31-day coverage period. If you do not contact your employer or plan sponsor, coverage for that child will end after the 31-day automatic coverage period.

Qualified Medical Child Support Orders (QMCSO): A medical child support order is a judgment, decree, or order made by a court of competent jurisdiction or an authorized state administrative agency that is made under state domestic relations law or state laws relating to medical child support. The order provides for medical support or health benefit coverage for a child of a Member under a group health plan. A QMCSO is a medical child support order that contains at least the following information: (1) the name and last known mailing address of the Member and each child to be covered under the QMCSO ; (2) a reasonable description of the type of health coverage to be provided to each child, or the manner in which such coverage is to be employers offer coverage to domestic partners of the same and/or the opposite sex. This is called Domestic Partner 1Some coverage and, if offered, is included in your medical plan documents.

2Days in the Certificate refers to calendar days unless stated as business days.

3The order may substitute the name and mailing address of a state or local official for a child’s mailing address.

–  –  –

Disabled dependents: The disabled dependent child, as medically certified by a physician due to mental or physical disability, mental illness, or developmental disability, who became so prior to the attainment of age

nineteen (19) must:

• Be unmarried and remain unmarried while enrolled in UPMC Vision Care;

• Be chiefly dependent (more than 50%) upon the Contract Holder for support and maintenance; and

• Be the child of the Contract Holder (either from birth, as a stepchild, or through legal adoption) or a child for whom the Member is legally obligated to provide support pursuant to a QMCSO.

Loss of other vision coverage: You may enroll yourself or a dependent for whom you previously declined coverage

because you or your dependent had vision benefits, within 31 days of the loss of such coverage, if:

–  –  –

The termination of the prior coverage must have occurred due to your or the dependent’s loss of eligibility for such coverage or the termination of an employer or plan sponsor’s contribution toward the premium for the coverage. To be eligible for this special enrollment period, prior coverage must not have been terminated because of your or your dependent’s failure to make timely premium payments or for cause (for example, making a fraudulent claim).

Enrolling or changing enrollment status You may apply for enrollment or change the enrollment status for yourself or a dependent during open enrollment or within 31 days of an individual becoming eligible for coverage. To apply for enrollment or change enrollment status, complete and submit an enrollment form to your employer or plan sponsor. Remember that, for the Plan to properly manage your benefits and coverage, you must keep your employer or plan sponsor up to date regarding any changes in your contact information (address, telephone number, etc.) and changes in your family status (marriages, deaths, births, etc.).

The restriction on enrolling new dependents only during open enrollments when the Member fails to enroll them within 31 days of a life- changing event does not apply to dependent children of a Member subject to a court or administrative order of support relating to the provision of health care coverage.

When will your coverage begin?

Your coverage will begin on the effective date communicated to you by your employer or plan sponsor. Note that some employers set minimum waiting periods before your coverage will be effective.

–  –  –

Military leave If an eligible dependent child who is a member of the Pennsylvania National Guard or any reserve component of the United States Armed Forces and a full-time student at a school, college, or university has been called to active duty (other than active duty for training) for a period of 30 or more consecutive days, that dependent is eligible for an extension of coverage for a period equal to the duration of active duty service or until the dependent is no longer a fulltime student. Eligibility of a dependent called to active duty may not be terminated by reason of age when his or her enrollment was interrupted because of such military duty.



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