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Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - Moore Wallace Detailed Table of Contents
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Table of Contents
Detailed Table of Contents
Index

Introduction

Who Is Eligible

Retiree Eligibility Requirements

Benefits-Eligible Position

Examples

If You Are Involuntarily Separated

If You Are on an Authorized Leave of Absence

If You Die

Spouse Eligibility Requirements

Domestic Partner Eligibility Requirements

Enrolling for Coverage

General Information

Enrolling Yourself and Your Spouse/Domestic Partner

Eligible Surviving Spouse/Domestic Partner’s Enrollment

If You or Your Spouse/Domestic Partner Is Receiving Treatment When Coverage Begins

Program Premium Cost

Determining an Annual Premium for You and Your Spouse/Domestic Partner

Total Cost of Coverage

If You Are Not Eligible for an Annual Subsidy Cap Amount

How Your Monthly Contributions Change When You or Your Spouse/Domestic Partner Becomes Eligible for Medicare

Making Required Premium Payments

Your Rights and Responsibilities

General Information

Your Rights

Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act

Your Responsibilities

How the Retiree Group Health Program Works

General Information

Deductibles

Coinsurance

Out-of-Pocket Limits

Lifetime Maximum Benefit

Glossary of Key Terms

Retiree Group Health Program Design – Medical Programs

Primary Care Physicians (PCPs)

Specialty Care

Emergency Care

Urgent Care

Retiree Group Health Program Design – Mental Health and Substance Abuse Program

A Summary Chart of the Retiree Group Health Program – CIGNA Open Access Plus

A Summary Chart of the Retiree Group Health Program – CIGNA Indemnity

A Summary Chart of the Retiree Group Health Program – CIGNA Post-65 Medicare

Retiree Group Health Program – Other Services Available

Disease Management Services

CIGNA HealthCare Healthy Rewards

CIGNA HealthCare Health Information Line

CIGNA HealthCare Health Information Library

CIGNA HealthCare Medical Self-Service

Preadmission Certification – CIGNA

How to Precertify Your Hospital Admission

If You Do Not Precertify a Hospital Admission

Emergency Notification

What Is an Expense That May Be a Covered Expense – Medical Program

Professional Services

Reproductive Services

Outpatient Hospital/Facility and Emergency Room Services

Inpatient Hospital Services

Miscellaneous Services

What Expense is Excluded From Being a Covered Expense – Medical Program

What Is an Expense That May Be a Covered Expense – Mental Health and Substance Abuse Program

What Expense is Excluded From Being a Covered Expense – Mental Health and Substance Abuse Program

How the Prescription Drug Program Works

General Information

Glossary of Key Terms

Prescription Drug Program Design

A Summary Chart of Your Prescription Drug Coverage

What Is an Expense That May Be a Covered Expense – Prescription Drug Program

What Expense Is Excluded From Being a Covered Expense – Prescription Drug Program

Prior Authorization

How to Fill Your Prescriptions at a Retail Pharmacy

How to Fill Your Prescriptions through the Mail Service Pharmacy

Your Legal Right to Continuation Coverage

General Information

Notification

Election Procedure

Payment

When Continuation Coverage Ends

Trade Act Implications

Coordinating Benefits With Other Programs

General Information

How Coordination of Benefits Works

Medicare

Medicare Part A (Hospital Insurance) and Part B (Medical Insurance)

Examples

Medicare Part C

Medicare Part D

How to File a Claim

General Information

Retiree Group Health Program Claims

Medicare Electronic Claim Submission (Medicare Crossover)

Filling Prescriptions at Non-Participating Retail Pharmacies

ERISA Claims and Appeals Procedures

General Information

Procedure for Filing a Claim

Defective Claims

Initial Claim Review

Initial Benefit Determination

Claim Involving Urgent Care

Concurrent Care Decision

Pre-Service Claim

Post-Service Claim

Manner and Content of Notification of Denied Claim

Review of Initial Benefit Denial

Procedure for Filing an Appeal of a Denial

Review Procedures for Denials

Timing of Notification of Benefit Determination on Review

Manner and Content of Notification of Benefit Determination on Review

Legal Action

Situations Affecting Your Benefits

General Information

Right of Recovery

Right to Reimbursement, Assignment of Rights, and Duty to Notify

Right to Reimbursement

Assignment of Rights

Duty to Notify

If the Plan Is Modified or Ended

Administrative and Contact Information

General Information

Type of Plan

Plan Sponsor

Employer Identification Number of Plan Sponsor

Plan Name and Number

Plan Year End

Agent for Service of Legal Process

Benefits Committee and Plan Administrator

Eligibility Administration

Claims Administrator and Network Manager

Claims Administrator for Eligibility Claims

COBRA Administrator for Continuation Coverage

Allocation and Delegation of Fiduciary Responsibilities by the Benefits Committee

Trust and Insurance

Self-Funded Benefits

Insured Benefits

Participating Employers

Special Rules for Certain Participants

Who Is Eligible – Closed Eligibility Group

Moore Pre-1979 Retiree Group

Moore 1979 – 1986 Retiree Group

Moore 1986 – 1994 Retiree Group

Moore Post-4/1/1994 Retiree Group

Wallace Subsidized Retiree Group

Wallace, Litho, Nielsen Unsubsidized Retiree Group

Wallace, Litho, Nielsen Retiree Group (retired on or after January 1, 2004)

Program Premium Cost

Cap on Company Subsidies

Retiree Waive Credit Program

Retiree Health Care Account (RHCA)

If You Retired From Moore Prior to July 1, 1997

If You Retired From Moore on or After July 1, 1997

Using Your RHCA to Reimburse the Cost of Coverage

Filing for Reimbursement Under the RHCA Plan

Deadline to Submit Claims

Special Disqualification Rule Regarding Competition

Retiree Group Health Program Summary

How the UHC Retiree Group Health Program Option Works

General Information

Lifetime Maximum Benefit

Glossary of Key Terms – UnitedHealthcare

General Information – UnitedHealthcare

Plan Design Information – UnitedHealthcare

Deductibles

Coinsurance

Emergency Care

Urgent Care

Mental Health and Substance Abuse Services

A Summary Chart of the $200 Retiree Deductible Plan Option

A Summary Chart of the $275 Retiree Deductible Plan Option

Special Services Available – UHC

NurseLine

MyUHC.com

Prior Notification Requirements

Preadmission Certification – UHC

How to Precertify Your Hospital Admission

If You Do Not Precertify a Hospital Admission

Emergency Notification

What Is Covered – UHC

Ambulance Services – Emergency Only

Bariatric Surgery

Dental Services – Accident Only

Durable Medical Equipment

Emergency Health Services

Home Health Care

Hospice Care

Hospital – Inpatient Stay

Injections

Maternity Services

Mental Health and Substance Abuse Services

Outpatient Surgery, Diagnostic, and Therapeutic Services

Physician’s Office Services

Professional Fees for Surgical and Medical Services

Prosthetic Devices

Reconstructive Procedures

Rehabilitation Services – Outpatient Therapy

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Spinal Treatment, Chiropractic, and Osteopathic Manipulative Therapy

Temporomandibular Joint Dysfunction (TMJ)

Transplant Services

Urgent Care Services

What Is Not Covered – UHC

Alternative Treatments

Comfort or Convenience Services

Dental Services

Drugs

Experimental or Investigational Services or Unproven Services

Foot Care

Infertility Services

Medical Supplies and Appliances

Mental Health and Substance Abuse Services

Nutrition

Physical Appearance

Providers

Reproduction

Services Provided Under Another Plan

Transplants

Vision and Hearing

All Other Exclusions

How to File a Claim Under the UnitedHealthcare Plans

General Information

UHC Retiree Group Health Program Claims

Your ERISA Rights

General Information

Receive Information About Your Program and Benefits

Continue Group Health Plan Coverage

Prudent Actions by Plan Fiduciaries

Enforce Your Rights

Assistance With Your Questions

Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - Moore Wallace

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Program Premium Cost

Making Required Premium Payments

How you and your spouse/domestic partner pay premiums to the Plan depends on whether or not you receive a monthly pension from the Pension Plan maintained by a Participating Employer and, if you do, your monthly pension amount. If you receive a pension from another employer’s plan, premiums are not deducted from the other pension. Premiums for you and your spouse/domestic partner can be paid in the following manner:

If your monthly pension benefit from your Participating Employer’s Pension Plan (after taxes are withheld) is more than the monthly premiums for coverage for you and your spouse/domestic partner under the Program, premiums for coverage for you and your spouse/domestic partner automatically are deducted from your pension each month. If your monthly pension benefit starts after applicable premiums under the Program are due (without benefit of the 30-day grace period) for you and your spouse/domestic partner, you will be billed until your pension benefit starts.

If you do not want monthly premiums for coverage under this Program automatically deducted from your pension each month, you may at any time elect to receive a monthly invoice. You may pay the monthly invoice for coverage for you and your spouse/domestic partner with a personal check, or you may elect to have the required premium deducted from a bank account of your choice. Contact the Benefits Center if you want to arrange this payment option.

If your monthly pension benefit from your Participating Employer’s Pension Plan is less than the monthly premiums for coverage for you and your spouse/domestic partner under the Program, or if you are not receiving a pension payment, you will receive an invoice by mail each month.

The first payment for you and your spouse/domestic partner is due on or before the effective date of coverage, which is the first of the month. If payment is not received within 30 days of the effective date of coverage, all coverage for you and your spouse/domestic partner retroactively is terminated, and you and your spouse/domestic partner will not be able to reenroll in the Program until the next Annual Enrollment.

For ongoing premium payments, payment for you and your spouse/domestic partner is due the first of the month, and you have a 30-day grace period for payment. If you are more than 30 days late with your payment, coverage will be retroactively discontinued to the last date for which full payment was received, and you and your spouse/domestic partner will not be able to reenroll in the Program until the next Annual Enrollment.

If you choose the Social Security Leveling option as your pension payment method, your pension amount from your Participating Employer’s Pension Plan is greater before you are eligible to start receiving your Social Security payment (age 62) and less once you attain age 62. As described above, if your pension amount is greater than the premiums for coverage for you and your spouse/domestic partner under the Program (after taxes are withheld), the premium for you and your spouse/domestic partner will automatically be deducted from your pension. If your pension amount at age 62 is less than the required premium for coverage for you and your spouse/domestic partner, you will begin receiving monthly invoices. If, after age 62, your pension amount decreases to $0, you will receive monthly invoices both before and after age 62.

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