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«Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Welcome ...»

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Your Benefit Guide

State Vision Plan

For Active Employees and Retirees

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Welcome

Welcome to your State Vision Plan, administered by Blue Cross Blue Shield of Michigan (BCBSM) under the

direction of the Michigan Civil Service Commission (MCSC).

The MCSC is responsible for implementing your vision benefits and future changes in benefits. BCBSM will provide certain services on behalf of the MCSC through an administrative-service-only contract. Your benefits are not insured with BCBSM, but will be paid from funds administered by the MCSC.

BCBSM is committed to providing you with excellent value and quality service and we want you to understand how your vision coverage works. With this in mind we have designed this booklet as an easy-to-read guide to your vision program. Please read it and make sure you understand what vision services are covered and when you are responsible for out-of-pocket costs.

If you have any questions about your State Vision Plan, please call the BCBSM State of Michigan Customer Service Center. The toll free telephone number is 800-843-4876 (TTY 800-240-3050). Our customer service representatives are available Monday through Friday from 8 a.m. to 6 p.m., excluding holidays.

This document is not a contract. Rather, it is intended to be a summary description of your State Vision Plan benefits. Every effort has been made to ensure the accuracy of this information. However, if statements in this description differ from the applicable coverage documents, the terms and conditions of the applicable coverage documents will prevail.

This guide replaces any prior descriptions of benefit information you may have received. Please discard any prior descriptions of your benefits.

Your Benefit Guide State Vision Plan Table of Contents Blue Cross Blue Shield of Michigan Contact information

Calling

Special servicing numbers

Writing

Visiting

Additional BCBSM walk-in centers

Internet access

State of Michigan contact information

Your Blue Cross Blue Shield of Michigan ID card

Explanation of benefit payment

Eligibility guidelines

Employees

Retirees

The State Employees Defined Benefit (DB) Plan

State Employees Defined Contribution (DC) Plan

Applying for coverage

Employees

Retirees

Dual eligibility

Making coverage changes

Employees

Retirees

Address changes

Terminating coverage

Employees

Retirees

Dependent coverage

Dependent exclusions

Terminating dependent coverage

Employees

Retirees

Continuing coverage for dependent children

Continuing coverage for incapacitated children

Continuing coverage while on a leave of absence or layoff

Certificate of creditable coverage

Your Benefit Guide State Vision Plan i Your State Vision Plan benefits

Choosing your vision provider

Copayments and out-of-pocket costs

What is covered

What is not covered

State of Michigan Vision Plan Summary of Benefits for Employees

State of Michigan Vision Plan Summary of Benefits for Retirees

Filing claims

Coordination of benefits

How COB works

COB guidelines

Filing COB claims

Updating COB information – your responsibility

Subrogation

Your right to file a grievance

Internal grievances

Standard internal grievance procedure

Expedited internal grievance procedure

Sections 402 and 403 of Public Act 350

What we may not do

What we must do

Appeals to Civil Service

Glossary

–  –  –

Calling Our customer service hours are Monday through Friday from 8 a.m. to 6 p.m. We are closed on holidays.

In and outside Michigan

Special servicing numbers Anti-fraud hotline

Hearing-impaired customers

BlueCard®

–  –  –

1st line: Enrollee Name is the name of the person who holds the contract. All communications are addressed to this name. Only the enrollee’s name appears on the ID card. However, the cards are for use by all covered members.

2nd line: Enrollee ID identifies your records in our files.

The alpha prefix preceding the enrollee ID number identifies that you have coverage through the State Vision Plan.

3rd line: Issuer identifies you as a BCBSM member. The number 80840 identifies our industry as an insurance carrier.

4th line: Group Number tells us you are a BCBSM group member.

On the back of your ID card, you will find:

• A magnetic strip which will help providers process your claims. It includes information from the front of the card and the enrollee’s date of birth. It does not include any benefit or health information.

• BCBSM’s toll-free customer service telephone numbers to call us when you have a claim or benefit inquiry.

Here are some tips about your ID card:

• Carry your card with you at all times.

• If you or anyone in your family needs an ID card, please go to the secured site at bcbsm.com and request one, or call the BCBSM State of Michigan Customer Service Center for assistance.





• Call the BCBSM State of Michigan Customer Service Center if your card is lost or stolen. You can still receive services by giving the provider your Enrollee ID number to verify your coverage.

Only you and your eligible dependents may use the cards issued for your contract. Lending your card to anyone not eligible to use it is illegal and subject to possible fraud investigation and termination of coverage.

Your Benefit Guide State Vision Plan 3 Explanation of benefit payment You will receive an Explanation of Benefit Payments (EOBP) form each time we process a claim under your contract number. The EOBP is not a bill. It is a statement that helps you understand how your benefits were

paid. It tells you:

• The family member who received services • Who provided the service, the payments made and any amount saved by using a participating provider • Helpful Information about BCBSM programs • Service dates, charges, payments and any balance you may owe You may access your EOBP forms online by visiting bcbsm.com and signing in at the Members Secured Services site. You may also receive your EOBP by mail.

Please check your EOBPs carefully. If you see an error, please contact your provider first. If they cannot correct the error, call the BCBSM State of Michigan Customer Service Center.

If you think your provider is intentionally billing us for services you did not receive, or that someone is using your BCBSM ID card illegally, contact our anti-fraud toll free hotline. Your call will be kept strictly confidential.

4 Your Benefit Guide State Vision Plan Eligibility guidelines Employees You are eligible to enroll in the State Vision Plan on the first day of the bi-weekly payroll period following your first day of employment. You must contact MI HR Service Center to enroll in the State Vision Plan. You are

eligible to enroll in the State Vision Plan if:

• You are a State employee • You have an appointment of at least 720 hours You are not eligible to enroll if you have a non-career appointment.

Retirees The State Employees Defined Benefit (DB) Plan The State Employees Defined Benefit Plan covers most State employees hired before March 31, 1997.

This includes Civil Service employees, appointed officials in the executive branch, and employees of the legislature and judiciary branch, as well as certain employees of non-central agencies.

If you retire under the State’s DB plan, you can continue coverage without interruption if you receive an immediate retirement benefit under the State Employees Retirement Act (SERA) or the State Police Retirement Act (SPRA).

• SERA retirees can find additional information at:

http://www.michigan.gov/orsstatedb/0,1607,7-208-30607_48436---,00.html • SPRA retirees can find additional information at:

http://www.michigan.gov/orsmsp/0,1607,7-224-40611_41901---,00.html If you need information on applying, changing or canceling coverage as well as the effects of other group coverage, visit: http://www.michigan.gov/orsstatedb/0,1607,7-208-30607_48436_48437---,00.html#EnrChng State Employees Defined Contribution (DC) Plan Most State employees hired on or after March 31, 1997 are in the 401(k) (DC) Plan, where the State contributes an amount equal to four percent of gross salary. In addition, the State matches any contributions you make to the account, up to another three percent. The retirement benefit is based on the amount of contributions and the performance of the investments you select for those contributions.

• DC retirees can obtain information on premium rates and plans at:

http://www.michigan.gov/documents/orsstatedc/R0749G-InsRatesDC_332231_7.pdf • If you have questions about your 401(k) and 457 plans, or questions about

eligibility including vesting, disability, death and insurance benefits, visit:

https://stateofmi.ingplans.com/einfo/pdfs/msgs/client/benefitguide__20090731_134101.pdf Your insurance eligibility as a retiree begins on your retirement effective date, the first day of the month after you terminate employment. Since your coverage as an active employee continues through the end of the month in which you terminate employment, there should be no break in coverage as you go from active to retired status.

You can continue your vision coverage without interruption if:

• You terminated employment and have the equivalent of at least 10 years of full time State service.

You must be age 60 or meet the DC age and service requirements.

• You receive an immediate defined benefit pension under one of the following:

— State Employees’ Retirement Act — State Police Retirement Act Your Benefit Guide State Vision Plan 5 Applying for coverage Employees You may enroll for vision coverage when you meet the State Vision Plan requirements for eligibility. You may enroll yourself and your eligible dependents within the first 31 days of your hire date. You must enroll by contacting the MI HR Service Center.

Note: Employees who work for an agency that does not participate with the MI HR Service Center must contact their respective agency’s human resource office.

Retirees To apply for the State Vision Plan coverage or to ensure uninterrupted coverage, go to www.michigan.gov/orsmiaccount. You can also download an Insurance Enrollment Change/Request form (R0452G) available on the ORS Web site at http://www.michigan.gov/documents/orsstatedb/R0452GH_244205_7.pdf.

Your insurance begins on your retirement effective date. Since your coverage as an active employee continues through the end of the month in which you terminate employment, there should be no gap in coverage as you go from active to retired status. However, if you file your application after the month in which you terminate employment, or if you waive coverage when you are first eligible, there could be a six-month delay in your coverage.

If you have a qualifying event, the six-month waiting period can be waived, and coverage can begin the first day of the second month after ORS receives your materials. The following are considered qualifying events for the purpose of adding or deleting a dependent. ORS must receive your application and the supporting documentation for a qualifying event by mail within 30 days of the qualifying event to waive the six-month waiting period. Photocopies are acceptable.

• Adoption: Acceptable proof is adoption papers, a sworn statement with the date of placement, or a court order verifying placement. In a legal adoption, a child is eligible for coverage as of the date of placement. Placement occurs when you become legally obligated for the total or partial support of the child in anticipation of adoption.

• Birth: Acceptable proof is a birth certificate.

• Death: Acceptable proof is original death certificate.

• Divorce: Acceptable proof is divorce papers.

• Marriage: Acceptable proof is a marriage certificate.

• Involuntary loss of coverage in another group plan: Provide a statement on letterhead from the terminating group insurance plan explaining who was covered, why coverage is ending, and the date coverage ends.

ORS can waive the six-month waiting period if you complete your insurance change request through miAccount and we receive, by mail, your confirmation page and required proofs, or an Insurance Enrollment/Change Request (R0452G) and required proofs within 30 days of the qualifying event. Coverage can begin the first of the month following the month in which we receive your completed application and required proofs.

6 Your Benefit Guide State Vision Plan Dual eligibility

If you and your spouse are both covered by the State Vision Plan (retiree or active), you may:

• Maintain separate coverage through your individual plans, or • Enroll in one plan, with one of you as a dependent If you choose to maintain separate coverage, your child or children can only be covered by one of the parent’s plans, not both. This applies even if you are divorced.

If you or your spouse separate from State service, take a leave of absence, or are laid off, the departing employee may be enrolled as a dependent on the remaining employee’s State Vision Plan coverage,

providing the remaining employee:

• Continues to meet eligibility requirements;

• Was covered as a dependent of the departing employee or was enrolled separately as an employee;

and • Notifies MI HR Service Center of his or her intent to transfer enrollment prior to the departure of the spouse from State service.

Once you return to work, you must wait until the State’s next open enrollment period before you may transfer your coverage back into your own name.

Your Benefit Guide State Vision Plan 7 Making coverage changes Employees You can make mid-year enrollment changes to your coverage based on a family status change. These



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