The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Appealing a Prior Authorization Decision If you disagree with BCBS’ prior authorization determination, you can seek additional review of that claim by following the procedure described under “Request for Review of Adverse Benefit Determinations” in the “Internal ERISA Claims Procedures” section in this SPD. When You Have Other Coverage – BCBS of MN If you or your dependents are covered by the Early Retiree Medical or Comprehensive option and by another employer’s health plan, the U.S. Bank option will integrate its payments for medical related services with those of the other group plan. For information related to pharmacy, see the “When You Have Other Coverage – Medco” section in this SPD. The U.S. Bank options do not integrate payments with non-group health plans or individual polices issued in most states.* * Pursuant to law, some states are required to integrate with non-group or individual health plans. In these instances, normal rules (as explained above) are followed for determining which plan is primary. Integration means that benefits from both plans are coordinated. You and your dependents will not, in most cases, receive 100% reimbursement for health care expenses when you have coverage in two group plans. If certain benefit plans are structured identically, the secondary plan might not pay any benefits. As a result, it may not be economically advantageous to be covered by two group plans. In order for integration to occur, one of the plans is determined to be primary and the other, secondary. The primary plan pays first and the secondary plan pays second. The following rules apply to determine which plan is primary: • Plans providing benefits or services under workers’ compensation, personal injury protection (PIP) or no-fault insurance are always considered primary. • Dependents of pre-65 non-Medicare eligible retirees eligible for Medicare solely on the basis of having end-stage renal disease (first 30 months only), the benefit option is primary. • A plan that covers a person as an employee or a dependent of an employee is primary over a plan that covers a person under COBRA or other continuation coverage required by statute. • A retiree’s health plan is considered primary for the retiree unless the retiree is also covered by an active employee plan. A plan that covers the retiree as a dependent (unless it is an active employee plan) is secondary. • If a retiree or dependent is covered by an active employee plan, the active plan is considered primary for that individual. • For dependent children covered by the plans of both parents, the “birthday rule” applies, which means the plan of the parent whose birthday falls earlier in the year pays first. • Dependents of pre-65 non-Medicare eligible retirees eligible for Medicare due to disability and who are not working, Medicare Parts A and B are primary. • For children of legally separated or divorced parents, the plan of the parent who has child custody pays first (unless the divorce decree indicates otherwise). • If you remarry or enter into a domestic partnership and you have custody, your plan is primary - followed by your new spouse’s/domestic partner’s plan and then your former spouse’s/domestic partner’s plan. 54
Retiree Health Care SPD Effective January 1, 2012 How Integration Works When your U.S. Bank Retiree Health Care Program is the secondary plan, the medical bill must first be submitted to the other group plan (the primary plan) for payment. The bill should then be sent, along with the “Explanation of Benefits” from the primary plan, to BCBS of MN at the following address: BCBS of Minnesota 3535 Blue Cross Road P.O. Box 64560 St. Paul, MN 55164 The amount the Program pays equals what the Program would have paid if it were primary MINUS what the primary plan paid. Refer to the following examples: Examples of Integration Early Retiree Medical Option Early Retiree Medical Option Family coverage (In-Network) Family coverage (In-Network) Total charge $5,000 $5,000 What U.S. Bank would pay if it $1,500 ($5,000 minus 3000 $1500 ($5,000 minus $3000 were primary plan deductible = $2000 X deductible = $2000 X 75%) 75%) What primary plan pays $2,700 $1,200 What U.S. Bank Health Care $0 Difference between what $300 Difference between Program pays primary plan pays and what primary plan pays what U.S. Bank Program and what U.S. Bank would have paid if it were Program would have primary paid if it were primary What YOU pay $2,300 ($5,000 - $2,700) $3500 ($5,000 - $1,200 - $300) In determining how to integrate benefits, BCBS will need to receive and release medical (and possibly other) information. Except as otherwise required by applicable law BCBS does not need to tell you or get your consent to exchange needed information with other organizations to apply the integration-of-benefit rules. Liability of Another Party: When Another Person is Responsible for Your Covered Health Care Expenses As a condition of receiving benefits under the U.S. Bank Retiree Health Care Program, you agree to assign and subrogate any and all of your rights of recovery from any other liable party. This means that if you or a covered dependent becomes ill or is injured by another party, and the U.S. Bank Retiree Health Care Program pays expenses for which another party is liable, you are required to reimburse the Program from what you receive from the legally responsible party or from any settlement or judgment. You also agree not to do anything to interfere with the plan’s right to recovery. Failure to comply with these requirements will result in loss of benefits. You may be required to sign an agreement to this effect. (There are other important requirements concerning the Program’s reimbursement and subrogation rights. See the “Benefits Administrative Information” section in this SPD.) 55
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