Mesa Unified School District #4
Employee Benefit Trust
Plan Document
Describing theself-funded
Medical Plans, DentalPPO Plan,and VisionPPO Plan
Amended, restated, and effective October 1, 2017
TABLE OF CONTENTS
INtroduction
QUICK REFERENCE CHART
ELIGIBILITY
MEDICAL PLANS
SCHEDULE OF MEDICAL BENEFITS
MEDICAL NETWORKS
CARE COORDINATION/UTILIZATION MANAGEMENT (UM)......
MEDICAL PLAN EXCLUSIONS......
VISION PPO PLAN......
DENTAL PPO PLAN......
Dental HMO plan......
LIFE INSURANCE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
CLAIM FILING AND APPEAL INFORMATION......
COORDINATION OF BENEFITS (COB)......
COBRA: TEMPORARY CONTINUATION OF HEALTH CARE COVERAGE.....
GENERAL PROVISIONS......
DEFINITIONS......
To:Eligible employees and their dependents
We are pleased to describe the self-funded medical, dental, and vision benefits available to eligible Mesa Public Schools employees and their dependents. Benefits constitute a significant portion of your overall compensation and are sometimes overlooked until we suffer an adverse personal or family illness. We are confident you realize the value of the health care coverage we offer.
Please read this booklet carefully so that you are aware of the benefit coveragesavailable to you through our medical, dental and vision plans. Keep this document, along with any notices of Plan changes, in a safe and convenient place where you and your family can find and refer to them. Be sure to read the Schedule of Medical Benefits, Exclusions and Definitions chapters. Remember, not every expense you incur for care is covered by this Plan.
YOU ARE RESPONSIBLE FOR REVIEWING THE PLAN REQUIREMENTS OUTLINED IN THIS BOOKLET AND YOU MUST PROVIDE THE INFORMATION TO YOUR COVERED DEPENDENTS.
This Plan Document is effective October 1, 2017, but is subject to revision. As the Plan is amended from time to time, you will be notified of the changes. If those later notices describe a benefit or procedure that is different from what is described here, you should rely on the later information.
The program allows for choices among a variety of benefits to meet your needs and the needs of your family. We encourage you to use benefits wisely and wish you and your family the best health.
Sincerely,
The Governing Board of
Mesa Unified School District No. 4
INtroduction
WHAT THIS DOCUMENT TELLS YOU
This Plan Document/Summary Plan Description describes the self-funded medical, dental, and vision benefits of Mesa Unified School District #4, hereafter referred to as “the Plan.” The Plan described in this document is effective October 1,2017, and replaces all other plan documents, summary plan descriptions,and applicable amendments to those documents previously provided to Plan participants.
- To determine if you are in a class of individuals who are eligible for benefits under this Plan, refer to the Eligibility chapter in this document. If you have declined any of the coverages described in this document, the chapters pertaining to those declined coverages do not apply to you.
- Note that your eligibility or right to benefits under this Plan should not be interpreted as a guarantee of employment.
- No individual shall have accrued or vested rights to benefits under this Plan. A vested right refers to a benefit that an individual has earned a right to receive and that cannot be forfeited. Plan benefits are not vested and are not guaranteed.
This document will help you understand and use the benefits provided by Mesa Unified School District. You should review it and share it with those members of your family who are or will be covered by the Plan. It will give all of you an understanding of the coverages provided; the procedures to follow in submitting claims; and your responsibilities to provide necessary information to the Plan. Be sure to read the Exclusions and Definitions chapters.
While recognizing the many benefits associated with this Plan, it is also important to note that not every expense you incur for health care is covered by this Plan.
All provisions of this document contain important information. If you have any questions about your coverage or your obligations under the terms of the Plan, be sure to seek help or information. A Quick Reference Chart to sources of help or information about the Plan appears in this chapter.
IMPORTANT INFORMATIONMesa Unified School District is committed to maintaining health care coverage for employees and their families at an affordable cost, however, because future conditions cannot be predicted, the Governing Board of Mesa Unified School Districtreserves the right to amend or terminate coverages at any time and for any reason. As the Plan is amended from time to time, you will be sent information explaining the changes. If those later notices describe a benefit or procedure that is different from what is described here, you should rely on the later information.
Be sure to keep this document, along with notices of any Plan changes, in a safe and convenient place where you and your family can find and refer to them.
This Plan is not established under and is not subject to the federal law, Employee Retirement Income Security Act of 1974, as amended, commonly known as ERISA. The medical plans, dental plan and vision plan described in this document are self-funded with contributions from Mesa Unified School District and Eligible Employeesheld in a Trust. Independent Claims Administrators under contract to the Plan pay benefits out of Trust assets. The contact information for the various claims administrators are listed on the Quick Reference Chart in this document. The Medical Plans described in this document do not apply a pre-existing condition limitation.
The brief life insurance information in this document comes from the insured life insurance benefit. The insured Dental HMO Plan is not fully described in this document.
SUGGESTIONS FOR USING THIS DOCUMENT
This document provides detail about your Plan. We suggest that you pay particular attention to the following:
- Read through this Introduction and look at the Table of Contents that immediately precedes it. If you don’t understand a term, look it up in the Definitions chapter. The Table of Contents provides you with an outline of the chapters. The Definitions chapter explains many technical, medical and legal terms that appear in the text.
- This document contains a Quick Reference Chart following this introductory text. This is a handy resource for the names, addresses, phone numbers and websites of the key contacts for your Plan such as the Claims Administrators or Employee Assistance Program (EAP).
- The Eligibility chapter outlines who is eligible for coverage and when coverage ends while the COBRA chapter discusses your options if coverage ends for you or a covered Spouse or Dependent Child.
- Review the Medical Plans, Schedule of Medical Benefits and Medical Plan Exclusions chapters. These describe your benefits in more detail. There are examples, charts and tables to help clarify key provisions and more technical details of the coverages.
- Review the Medical Networks and Care Coordination/Utilization Management chapters. They describe how you can maximize plan benefits by following the provisions explained in these chapters.
- Review the Dental PPO Planchapter that includes the Schedule of Dental PPO Plan Benefits and Dental Exclusions.There is also a chapter with highlights of the insured Dental HMO plan.
- Review the Vision PPO Plan chapter that contains details about the Schedule of Vision Benefits and Vision Exclusions.
- Review the chapter that highlights the insured Life Insurance chapter for information on life and accidental death and dismemberment insurance.
- Refer to the General Provisions chapter for information regarding your rights while the Claim Filing and Appeal Information chapter tells you what you must do to file a claim and how to seek review (appeal) if you are dissatisfied with a claims decision.
- The chapter on Coordination of Benefits discusses situations where you have coverage under more than one group health care plan, Medicare, another government plan, personal injury protection under mandatory no-fault automobile insurance coverage, workers’ compensation, or where you can recover expenses from any other source.
IMPORTANT: NOTIFYING THE PLAN
You or your Dependents must promptly furnish to the Plan Administrator information regarding change of name, address, marriage, divorce or legal separation, death of any covered family member, birth and change in status of a Dependent Child, Medicare enrollment or disenrollment, an individual no longer meeting the eligibility provisions of the Plan, or the existence of other coverage. Notify the Plan (the Employee Benefits Office) preferably within 31 days, but no later than 60 days, after any of the above noted events.
Failure to give this Plan a timely notice (as noted above) may cause your Spouse and/or Dependent Child(ren):
(a)to lose their right to obtain COBRA Continuation Coverage, or
(b)may cause the coverage of a Dependent Child to end when it otherwise might continue because of a disability, or
(c)may cause claims to not be able to be considered for payment until eligibility issues have been resolved, or
(d)may result in a participant’s liability to the Plan if any benefits are paid to an ineligible person.
An employee of the District could also face disciplinary action, termination of employment and/or criminal prosecution.
SPANISH LANGUAGE ASSISTANCE
Si usted no entiende la información en este documento, por favor de ponerse en contacto con personal del departamento de Beneficios en 480-472-7222.
QUESTIONS YOU MAY HAVE
If you have any questions concerning eligibility or the benefits that you or your family are eligible to receive, please contact the Employee Benefits Office at their phone number and address located on the Quick Reference Chart in this document. As a courtesy to you, the staff at the various claims administrators may respond informally to oral questions; however, oral communications are not binding on the Plan and cannot be relied upon in any dispute concerning your benefits. Your most reliable method is to put your questions into writing and fax or mail those questions to the Plan Administrator and obtain a written response from the Plan Administrator.
In the event of any discrepancy between any information that you receive from the staff at the various claims administrators, orally or in writing, and the terms of this document, the terms of this document will govern your entitlement to benefits, if any.
IMPORTANT NOTE REGARDING NEWBORN COVERAGECoverage of the newborn baby’s medical bills are automatically payable under the mother’s coverage for the first 48 hours after a vaginal birth or first 96 hours after a C-section birth. Thereafter,coverage is available for the newborn, ONLY if you follow the proper enrollment procedures described in the Eligibility chapter.
If you fail to request enrollment for your newborn within the first 31 days after the child’s birth, there will be no payment of claims related to the newborn beyond the timeframes noted above.
FOR HELP OR INFORMATION
When you need information, please check this document first. If you need further help, call the contacts listed in the following Quick Reference Chart:
QUICK REFERENCE CHART
Information Needed / Whom to ContactMedical Plans Claims Administrator
- Claim Forms (Medical)
- Medical Plan Claims and Appeals
- Eligibility for Coverage
- Plan Benefit Information
- Summary of Benefits and Coverage (SBC)
Open Access Plus (OAP or OA Plus) Customer Service:
1-800-244-6224 (1-800-CIGNA24)
HDHP Customer Service:
1-800-244-6224 (1-800-CIGNA24)
Website:
Claim Submittal Address:
CIGNA
MPS Group Number: 3333634
P. O. Box 182223
Chattanooga, TN 37422-7223
Appeals Submittal Address:
CIGNA Healthcare
MPS Group Number: 3333634
National Appeals Unit
P. O. Box 188011
Chattanooga, TN 37422
Medical Plans Provider Network
(called Open Access Plus or OAP or OAPlus)
- OAPlusMedical Network Provider Directory for the CIGNA Open Access Plus Network
- Additions/Deletions of Network Providers
- (Always check with the Network before you visit a provider to be sure they are still contracted and will give you the discounted price)
Open Access Plus (OAP or OA Plus) Customer Service:
1-800-244-6224 (1-800-CIGNA24)
HDHP Customer Service: 1-800-244-6224
Website: and select the Open Access Plus Network
CAUTION: Use of a non-network hospital, facility or Health Care Provider could result in you having to pay a substantial balance on the provider’s billing (see definition of “balance billing” in the Definition chapter of this document). Your lowest out of pocket costs will occur when you use In-Network providers.
Utilization Management (UM) Program
- Pre-authorization (precertification) of Admissions and Medical Services
- Case Management
- Appeals of UM decisions
Open Access Plus (OAP or OA Plus) Customer Service:
1-800-244-6224
HDHP Customer Service: 1-800-244-6224
Prescription Drug Plan
- ID Cards
- Retail Network Pharmacies
- Mail Order (Home Delivery) Pharmacy
- Prescription Drug Information
- Formulary of Value Drugs
- Precertification of Certain Drugs
- Direct Member Reimbursement (for Non-network retail pharmacy use)
- Specialty Drug Program: Precertification and Ordering
Customer Service: 1-800-244-6224
Specialty Drug Customer Service: 1-800-285-4812
CIGNA Home Delivery Pharmacy
Customer Service: 1-800-285-4812
P. O. Box 1019
Horsham, PA 19044
Website:
Quit Today Smoking Cessation Program:
Call 1-800-244-6224 to enroll
Employee Assistance Program (EAP)
- Professional, confidential information, support and referral to help individuals cope with personal problems that impact their home and work life. EAP counselors can help you with stress, marriage/family/work-related problems, substance abuse, financial and legal problems.
Telephone: 602-264-4600 or 1-800-327-3517
Website:
Enter username: MESAUSD
Enter password: eappreferred
Behavioral Health Program
for all medical plan options
- Mental Health and Substance Abuse Services and Providers
- Precertification of Certain Behavioral Health Services
- Behavioral Health Claims and Appeals
Customer Service: 1-800-244-6224 (1-800-CIGNA24)
Website: or
Healthy Pregnancy Healthy Babies Program
- The CIGNA Healthy Pregnancies, Healthy Babies® program can provide education and support throughout your entire pregnancy – and after. If you complete the program, you could be eligible to receive an incentive of up to $150.
Call 1-800-244-6224
Website:
Your Health First Program
Free health support services. CIGNA’s Your Health First health experts trained as nurses, pharmacists, behavioral clinicians and health educators. They’re available Monday through Saturday to speak with you one-on-one. They can help you find the best and most cost-effective health professionals and services in our area. You can call to ask questions about ways to improve your health and get additional information about medication and treatment options that your doctor may have mentioned.
- Improve your lifestyle with effective stress, tobacco or weight management.
- Better manage conditions such as depressions, asthma, diabetes and more
- Make the best decisions about treatment for common conditions like low back pain or heart disease.
- Find ways to reduce health care costs by savings money on medications, treatments or other health related expenses.
The phone number is on the back of your ID card or
call 1-800-244-6224.
Cancer Treatment Support Program
- CIGNA’s Cancer Care Support Program offers cancer assistance from Cigna nurse coaches as critical decisions are made regarding medical care, treatment and recovery.
- The CIGNA Cancer Support Program provides access to a specially trained cancer nurse to assist you one-on-one. Your nurse can help you understand your diagnosis, medications, treatment options identified by your doctor and help answer any questions you may have. In addition, CIGNA can help you coordinate your care, understand your insurance coverage, and find additional resources like local support groups and facilities.
from CIGNA
Call 1-800-244-6224
Website:
Dental PPO Plan Claims Administrator
- Dental PPO Network Provider Directory (CIGNA DPPO Advantage network)
- Dental PPO Plan Claims and Appeals
Customer Service: 1-800-244-6224 (1-800-CIGNA24)
Dental HMO Plan (Dental Care HMO)
- The insured Dental HMO plan benefits are NOT fully described in this document. Contact the Employee Benefits Office for further information.
Customer Service: 1-800-244-6224 (1-800-CIGNA24)
Website:
Vision PPO Plan Claims Administrator
- Vision PPO Network and Provider Directory
- Vision PPO Plan Claims and Appeals
Customer Service: 1-800-877-7195
Health Savings Account (HSA) Bank / HSA Bank
Contact CIGNA Customer Service: 1-800-244-6224
COBRA Administrator
- Information About Coverage
- Adding or Dropping Dependents
- Cost of COBRA Continuation Coverage
- COBRA Premium payments
- Second Qualifying Event and Disability Notification
ATTN: Employee Benefits Office
63 East Main Street Suite 101
Mesa, AZ 85201
Phone: 480-472-7222
Secure Fax: 480-472-0370
Employee Benefits Office
Plan Administrator
HIPAA Privacy and Security Officer
- Medicare Part D Notice of Creditable Coverage
- HIPAA Notice of Privacy Practice
63 East Main Street Suite 101
Mesa, AZ 85201
Phone: 480-472-7222
Secure Fax: 480-472-0370
Email:
Life Insurance and Accidental Death and Dismemberment Insurance
- The life insurance and accidental death and dismemberment insurance benefits are not fully described in this document. Contact the Employee Benefits Office for further information.
- Submit death claims to the Employee Benefits Office at: 63 East Main Street, Suite 101 Mesa, AZ 85201. Phone: 480-472-7222 Fax: 480-472-0370.
1-800-247-6875
Website:
Flex Benefits Claims Administrator
- Health FSA both General Purpose and Limited Purpose for HDHP participants
- Dependent Care FSA
Customer Service:1-800-244-6224 (1-800-CIGNA24)
Benefits Online Enrollment / BenefitFocus
1-877-336-8082
Plan Administrator/Plan Sponsor / Governing Board of the Mesa Unified School District #4
63 East Main Street, Suite 101 Mesa, AZ 85201
Phone: 480-472-7222 Fax: 480-472-0370
Email:
Web Site:
ELIGIBILITY
HOW AND WHEN COVERAGE BEGINS, IS MAINTAINED AND ENDS