MARINER FINANCE, LLC PPO 80/60 PLAN PLAN DOCUMENT …
MARINER FINANCE, LLC PPO 80/60 PLAN
PLAN DOCUMENT AND
SUMMARY PLAN DESCRIPTION
Effective Date: July 1, 2016
TABLE OF CONTENTS
SUMMARY PLAN DESCRIPTION.................................................................................. 1
SCHEDULE OF BENEFITS ............................................................................................ 4
Medical Benefits....................................................................................................................................................4 Prescription Drug Program .................................................................................................................................. 12
CIGNA PREFERRED PROVIDER OR NONPREFERRED PROVIDER ...................... 13
Cigna Preferred Providers....................................................................................................................................13 Nonpreferred Providers ....................................................................................................................................... 13 Referrals .............................................................................................................................................................. 13 Exceptions ........................................................................................................................................................... 13
MEDICAL EXPENSE BENEFIT.................................................................................... 15
Copay................................................................................................................................................................... 15 Deductibles .......................................................................................................................................................... 15 Coinsurance ......................................................................................................................................................... 15 Out-of-Pocket Expense Limit .............................................................................................................................. 15 Maximum Benefit ................................................................................................................................................ 16 Hospital/Ambulatory Surgical Facility ................................................................................................................ 16 Facility Providers.................................................................................................................................................16 Ambulance Services ............................................................................................................................................ 16 Emergency Room Services .................................................................................................................................. 17 Immediate Care Center ........................................................................................................................................ 17 In-Store Health Clinic..........................................................................................................................................17 Physician Services and Professional Provider Services.......................................................................................17 Second Surgical Opinion ..................................................................................................................................... 18 Diagnostic Services and Supplies ........................................................................................................................ 18 Transplant ............................................................................................................................................................ 18 Pregnancy ............................................................................................................................................................ 19 Birthing Center .................................................................................................................................................... 19 Birthing Class ...................................................................................................................................................... 19 Sterilization.......................................................................................................................................................... 20 Infertility Services ............................................................................................................................................... 20 Well Newborn Care ............................................................................................................................................. 20 Routine Preventive Care ...................................................................................................................................... 20 Women's Preventive Services ............................................................................................................................. 20 Hearing Benefit for Minor Children (Up to Age 19) ........................................................................................... 21 Outpatient Therapy Services................................................................................................................................21 Extended Care Facility ........................................................................................................................................ 21 Home Health Care ...............................................................................................................................................22 Additional Home Health Care Benefits ...............................................................................................................22 Hospice Care........................................................................................................................................................ 23 Durable Medical Equipment ................................................................................................................................ 24 Prostheses ............................................................................................................................................................ 24 Orthotics .............................................................................................................................................................. 24 Medical Foods ..................................................................................................................................................... 24 Dental Services .................................................................................................................................................... 25 Temporomandibular Joint Dysfunction ............................................................................................................... 25 Orthognathic Disorders........................................................................................................................................25 Special Equipment and Supplies.......................................................................................................................... 25 Cosmetic/Reconstructive Surgery........................................................................................................................25 Mastectomy (Women's Health and Cancer Rights Act of 1998) .........................................................................25
Mental & Nervous Disorders and Chemical Dependency Care...........................................................................26 Prescription Drugs ............................................................................................................................................... 26 Routine Patient Costs for Approved Clinical Trials ............................................................................................ 26 Podiatry Services ................................................................................................................................................. 27 Chiropractic Care.................................................................................................................................................27 Diabetic Education .............................................................................................................................................. 27 Nutritional Counseling/Medical Nutrition Therapy.............................................................................................27 Biofeedback ......................................................................................................................................................... 27 Surgical Treatment of Morbid Obesity ................................................................................................................ 27 Cochlear Implant ................................................................................................................................................. 27 Surcharges ........................................................................................................................................................... 27
MEDICAL EXCLUSIONS.............................................................................................. 28
PRESCRIPTION DRUG PROGRAM ............................................................................ 31
Pharmacy Option ................................................................................................................................................. 31 Pharmacy Option Copay......................................................................................................................................31 Mail Order Option ............................................................................................................................................... 31 Mail Order Option Copay .................................................................................................................................... 31 Covered Prescription Drugs.................................................................................................................................31 Specialty Pharmacy Program...............................................................................................................................32 Limits To This Benefit......................................................................................................................................... 32 Expenses Not Covered.........................................................................................................................................33 Notice of Authorized Representative...................................................................................................................33 Appealing a Denied Post-Service Prescription Drug Claim ................................................................................ 33 Notice of Benefit Determination on a Post-Service Prescription Drug Claim Appeal ........................................34 External Appeal ................................................................................................................................................... 34 Right To External Appeal .................................................................................................................................... 35 Notice of Right to External Appeal ..................................................................................................................... 35 Independent Review Organization.......................................................................................................................35 Notice of External Review Determination...........................................................................................................35 Expedited External Review ................................................................................................................................. 36
PLAN EXCLUSIONS .................................................................................................... 37
ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATE............................................... 39
Employee Eligibility ............................................................................................................................................ 39 Employee Enrollment .......................................................................................................................................... 39 Employee(s) Effective Date.................................................................................................................................39 Dependent(s) Eligibility....................................................................................................................................... 39 Dependent Enrollment ......................................................................................................................................... 40 Dependent(s) Effective Date................................................................................................................................40 Special Enrollment Period (Other Coverage) ...................................................................................................... 41 Special Enrollment Period (Dependent Acquisition) ........................................................................................... 41 Special Enrollment Period (Children's Health Insurance Program (CHIP) Reauthorization Act of 2009) ............ 42 Open Enrollment..................................................................................................................................................42
TERMINATION OF COVERAGE .................................................................................. 44
Termination of Employee Coverage .................................................................................................................... 44 Termination of Dependent(s) Coverage...............................................................................................................44 Leave of Absence ................................................................................................................................................ 44 Layoff .................................................................................................................................................................. 44 Family and Medical Leave Act (FMLA) ............................................................................................................. 44 Extension of Benefits For Inpatient or During Total Disability .......................................................................... 45
CONTINUATION OF COVERAGE ............................................................................... 46
Qualifying Events ................................................................................................................................................ 46 Notification Requirements...................................................................................................................................46 Cost of Coverage ................................................................................................................................................. 47 When Continuation Coverage Begins..................................................................................................................47 Family Members Acquired During Continuation ................................................................................................ 47 Extension of Continuation Coverage ................................................................................................................... 48 End of Continuation.............................................................................................................................................49 Special Rules Regarding Notices.........................................................................................................................49 Military Mobilization .......................................................................................................................................... 50 Plan Contact Information.....................................................................................................................................50 Address Changes ................................................................................................................................................. 50
MEDICAL CLAIM FILING PROCEDURE ..................................................................... 51
POST-SERVICE CLAIM PROCEDURE ................................................................................51
Filing a Claim ...................................................................................................................................................... 51 Notice of Authorized Representative...................................................................................................................51 Notice of Claim ................................................................................................................................................... 51 Time Frame for Benefit Determination ............................................................................................................... 52 Notice of Benefit Denial ...................................................................................................................................... 52 Appealing a Denied Post-Service Claim.............................................................................................................. 52 Notice of Benefit Determination on Appeal ........................................................................................................53 Foreign Claims .................................................................................................................................................... 54
PRE-SERVICE CLAIM PROCEDURE...................................................................................54
Health Care Management .................................................................................................................................... 54 Filing a Pre-Certification Claim .......................................................................................................................... 54 Notice of Authorized Representative...................................................................................................................55 Time Frame for Pre-Service Claim Determination..............................................................................................55 Concurrent Care Claims ...................................................................................................................................... 56 Notice of Pre-Service Claim Denial .................................................................................................................... 56 Appealing a Denied Pre-Service Claim ............................................................................................................... 57 Notice of Pre-Service Determination on Appeal .................................................................................................58 Case Management................................................................................................................................................58 Special Delivery Program....................................................................................................................................58
POST-SERVICE AND PRE-SERVICE CLAIM EXTERNAL APPEALS PROCEDURE ........59
External Appeal ................................................................................................................................................... 59 Right to External Appeal ..................................................................................................................................... 59 Notice of Right to External Appeal ..................................................................................................................... 59 Independent Review Organization.......................................................................................................................60 Notice of External Review Determination...........................................................................................................60 Expedited External Review ................................................................................................................................. 60
COORDINATION OF BENEFITS ................................................................................. 61
Definitions Applicable to this Provision..............................................................................................................61 Effect on Benefits ................................................................................................................................................ 62 Order of Benefit Determination ........................................................................................................................... 62 Coordination With Medicare ............................................................................................................................... 62 Limitations on Payments ..................................................................................................................................... 63 Right to Receive and Release Necessary Information ......................................................................................... 63 Facility of Benefit Payment ................................................................................................................................. 63 Automobile Accident Benefits............................................................................................................................. 63
SUBROGATION/REIMBURSEMENT........................................................................... 65
GENERAL PROVISIONS ............................................................................................. 67
Administration of the Plan...................................................................................................................................67 Applicable Law....................................................................................................................................................67 Assignment .......................................................................................................................................................... 67 Benefits Not Transferable....................................................................................................................................67 Clerical Error ....................................................................................................................................................... 67 Conformity With Statute(s) ................................................................................................................................. 67 Effective Date of the Plan .................................................................................................................................... 68 Fraud or Intentional Misrepresentation................................................................................................................68 Free Choice of Hospital and Physician ................................................................................................................ 68 Incapacity ............................................................................................................................................................ 68 Incontestability .................................................................................................................................................... 68 Legal Actions.......................................................................................................................................................68 Limits on Liability ............................................................................................................................................... 68 Lost Distributees..................................................................................................................................................69 Medicaid Eligibility and Assignment of Rights...................................................................................................69 Physical Examinations Required by the Plan ...................................................................................................... 69 Plan is Not a Contract .......................................................................................................................................... 69 Plan Modification and Amendment ..................................................................................................................... 69 Plan Termination ................................................................................................................................................. 69 Pronouns .............................................................................................................................................................. 70 Recovery for Overpayment..................................................................................................................................70 Status Change ...................................................................................................................................................... 70 Time Effective ..................................................................................................................................................... 70 Workers' Compensation Not Affected ................................................................................................................. 70
HIPAA PRIVACY .......................................................................................................... 71
Disclosure by Plan to Plan Sponsor ..................................................................................................................... 71 Use and Disclosure by Plan Sponsor ................................................................................................................... 71 Obligations of Plan Sponsor ................................................................................................................................ 71 Exceptions ........................................................................................................................................................... 72
DEFINITIONS ............................................................................................................... 73
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- mariner finance llc ppo 80 60 plan plan document
- i united states district court f western district of
- personal loans 101 understanding apr mariner finance
- please read this e signature disclosure and consent
- educating the next generation financial
- enrollment and statement of health md 21093 benelogic
- by order of the circuit court for baltimore city if
- here s what we explained to the mariner finance
Related searches
- mariner finance of virginia llc
- mariner finance richmond va
- mariner finance sign in
- mariner finance newport news va
- is mariner finance a scam
- mariner finance customer account center
- mariner finance pay bill online
- mariner finance hours of operation
- manage my mariner finance account
- mariner finance pay loan online
- mariner finance create an account
- mariner finance online payment